Healthcare Provider Details

I. General information

NPI: 1265481212
Provider Name (Legal Business Name): MICHAEL L NOVAK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

IV. Provider business mailing address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2020
  • Fax: 320-214-5761
Mailing address:
  • Phone: 320-235-2020
  • Fax: 320-214-5761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2543
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: