Healthcare Provider Details

I. General information

NPI: 1558360131
Provider Name (Legal Business Name): MICHAEL L NOWAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COUNTRY CLUB RD STE# 203
ROSWELL NM
88201-5205
US

IV. Provider business mailing address

350 W COUNTRY CLUB RD STE# 203
ROSWELL NM
88201-5205
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-4646
  • Fax: 575-625-8498
Mailing address:
  • Phone: 575-624-4646
  • Fax: 575-625-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2619
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA-1602-11
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: