Provider Demographics
NPI:1548520711
Name:NOVAK, LEAH MARIE (DO)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:NOVAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 151ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-7572
Mailing Address - Country:US
Mailing Address - Phone:763-760-4701
Mailing Address - Fax:
Practice Address - Street 1:11475 ROBINSON DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3746
Practice Address - Country:US
Practice Address - Phone:763-587-9000
Practice Address - Fax:763-587-9130
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1548520711OtherBCBS
P01224927OtherRAILROAD MEDICARE
MN1548520711Medicaid
1548520711OtherMEDICA
MN1548520711OtherBCBS