Provider Demographics
NPI:1528247392
Name:NOSACEK, IVAN J (DPM)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:J
Last Name:NOSACEK
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 1:3006 MITCHELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1300
Mailing Address - Country:US
Mailing Address - Phone:301-390-3338
Mailing Address - Fax:301-390-7738
Practice Address - Street 1:3006 MITCHELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1300
Practice Address - Country:US
Practice Address - Phone:301-390-3338
Practice Address - Fax:301-390-7738
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00982213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD066038800Medicaid
MD666RS829Medicare PIN
DC003916I63Medicare PIN
MD066038800Medicaid
U07548Medicare UPIN