Healthcare Provider Details

I. General information

NPI: 1871606426
Provider Name (Legal Business Name): ELIZABETH NOWAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 MORTON ST ELDER SERVICE PLAN
MATTAPAN MA
02126-2834
US

IV. Provider business mailing address

1135 MORTON ST ELDER SERVICE PLAN
MATTAPAN MA
02126-2834
US

V. Phone/Fax

Practice location:
  • Phone: 617-533-2400
  • Fax: 617-533-2401
Mailing address:
  • Phone: 617-533-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number244481
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: