Provider Demographics
NPI:1104870948
Name:NOVAK, EDWARD B (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-0240
Mailing Address - Country:US
Mailing Address - Phone:507-247-5921
Mailing Address - Fax:507-247-5184
Practice Address - Street 1:240 WILLOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-0240
Practice Address - Country:US
Practice Address - Phone:507-247-5921
Practice Address - Fax:507-247-5184
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00314383Medicaid
NYC09052Medicare UPIN
NY353201Medicare ID - Type UnspecifiedMEDICARE NUMBER