Healthcare Provider Details

I. General information

NPI: 1598762924
Provider Name (Legal Business Name): BRIAN NOVACK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29630 EUCLID AVE
WICKLIFFE OH
44092-1829
US

IV. Provider business mailing address

29630 EUCLID AVE
WICKLIFFE OH
44092-1829
US

V. Phone/Fax

Practice location:
  • Phone: 440-944-6665
  • Fax:
Mailing address:
  • Phone: 440-944-6665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-00-2998-N
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: