Provider Demographics
NPI:1992807770
Name:DR IVAN J NOSACEK PA
Entity type:Organization
Organization Name:DR IVAN J NOSACEK PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NOSACEK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-390-3338
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00982213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD066038800Medicaid
MD066038800Medicaid
MD666RMedicare PIN
DC538663Medicare PIN