Healthcare Provider Details

I. General information

NPI: 1003973645
Provider Name (Legal Business Name): RUSSELL WARREN NOVAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ARLINGTON ST SUITE 310
SARASOTA FL
34239-3506
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-6300
  • Fax: 941-917-6306
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME41051
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: