Healthcare Provider Details

I. General information

NPI: 1669096111
Provider Name (Legal Business Name): JACOB ALEXANDER MARTIN NOVACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 WATER ST STE 1
PORT HURON MI
48060-4408
US

IV. Provider business mailing address

22644 RIDGEWAY ST
SAINT CLAIR SHORES MI
48080-1476
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-7000
  • Fax:
Mailing address:
  • Phone: 586-216-2615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101028607
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: