Healthcare Provider Details

I. General information

NPI: 1477537264
Provider Name (Legal Business Name): STEPHEN T NOWICKI MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 FAIRCHILD CT
WOODLAND CA
95695-4321
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 530-668-2600
  • Fax: 530-669-5627
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA078949
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberA78949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: