Healthcare Provider Details

I. General information

NPI: 1922698679
Provider Name (Legal Business Name): MARK NOVAK SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST RECON BN BAS BLDG 4101 41 AREA
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

PO BOX 555584
CAMP PENDLETON CA
92055-5584
US

V. Phone/Fax

Practice location:
  • Phone: 224-343-3623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: