Healthcare Provider Details

I. General information

NPI: 1386614923
Provider Name (Legal Business Name): ROBERT H NOVACK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 RIVIERA DR
LAKE HAVASU CITY AZ
86403-5716
US

IV. Provider business mailing address

90 RIVIERA DR
LAKE HAVASU CITY AZ
86403-5716
US

V. Phone/Fax

Practice location:
  • Phone: 928-855-7800
  • Fax: 928-855-5392
Mailing address:
  • Phone: 928-855-7800
  • Fax: 928-855-5392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0180
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0180
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: