Provider Demographics
NPI:1386614923
Name:NOVACK, ROBERT H (DPM)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:NOVACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5716
Mailing Address - Country:US
Mailing Address - Phone:928-855-7800
Mailing Address - Fax:928-855-5392
Practice Address - Street 1:90 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5716
Practice Address - Country:US
Practice Address - Phone:928-855-7800
Practice Address - Fax:928-855-5392
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0180213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0065230OtherBCBS AZ
AZ700048Medicaid
AZAZ0065230OtherBCBS AZ
T41990Medicare UPIN
480016799Medicare PIN
0414850001Medicare NSC