Provider Demographics
NPI:1205868908
Name:NOVACK, PETER STEPHEN (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:STEPHEN
Last Name:NOVACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 HILL ST
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1566
Practice Address - Country:US
Practice Address - Phone:419-563-3247
Practice Address - Fax:419-563-3248
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0052402083P0901X, 207QA0401X
OH34005240208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0824531Medicaid
OH0824531Medicaid