Healthcare Provider Details

I. General information

NPI: 1689630808
Provider Name (Legal Business Name): JASON LYLE NOVICK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CAPITOLA AVE UNIT B
CAPITOLA CA
95010-2759
US

IV. Provider business mailing address

525 CAPITOLA AVE UNIT B
CAPITOLA CA
95010-2759
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-2132
  • Fax: 831-462-2930
Mailing address:
  • Phone: 831-462-2132
  • Fax: 831-462-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: