MEDICARE: ROGER L NOVACK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	G53779	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W3452	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104828706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER L NOVACK MD

Provider Business Mailing Address
First Line	:	1245 WILSHIRE BLVD
Second Line	:	380
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4810
Country	:	US
Telephone Number	:	213-483-8810
Fax Number	:	213-481-1503

Provider Business Practice Location Address
First Line	:	1245 WILSHIRE BLVD
Second Line	:	380
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4810
Country	:	US
Telephone Number	:	213-483-8810
Fax Number	:	213-481-1503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	02/08/2017

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Directions to “ ROGER L NOVACK MD” Practice Location

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