Healthcare Provider Details

I. General information

NPI: 1275511156
Provider Name (Legal Business Name): GREGORY DANIEL NOVAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 S CANDY LN
COTTONWOOD AZ
86326-4158
US

IV. Provider business mailing address

1200 N BEAVER ST PAYER CREDENTIALING
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-639-6180
  • Fax: 928-639-6698
Mailing address:
  • Phone: 928-773-2559
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number46598
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number41896
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: