Healthcare Provider Details

I. General information

NPI: 1619055878
Provider Name (Legal Business Name): EUGENE JAMES NOWAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 FENTON STREET SUITE 101
CHULA VISTA CA
91914-3516
US

IV. Provider business mailing address

2440 FENTON ST SUITE 101
CHULA VISTA CA
91914-3516
US

V. Phone/Fax

Practice location:
  • Phone: 619-420-1840
  • Fax: 619-420-9630
Mailing address:
  • Phone: 619-420-1840
  • Fax: 619-420-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20A7103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: