Healthcare Provider Details

I. General information

NPI: 1750411427
Provider Name (Legal Business Name): EUGENE J NOWAK DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 FENTON ST. 101
CHULA VISTA CA
91914
US

IV. Provider business mailing address

PO BOX 210160
CHULA VISTA CA
91921-0160
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 Code207ND0900X
TaxonomyDermatopathology Physician
License Number20A7103
License Number StateCA

VIII. Authorized Official

Name: DR. EUGENE JAMES NOWAK
Title or Position: PRESIDENT
Credential: DO
Phone: 619-420-1840