Provider Demographics
NPI:1770533606
Name:NOVOA, JOSE R (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:NOVOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S 77TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114
Mailing Address - Country:US
Mailing Address - Phone:402-934-4535
Mailing Address - Fax:402-934-5939
Practice Address - Street 1:140 S 77TH ST
Practice Address - Street 2:WORKFIT
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-934-4535
Practice Address - Fax:402-934-5939
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17836207P00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010051130OtherRAILROAD MEDICARE
002475OtherRAILROAD MEDICARE - GRP
NE47064207113Medicaid
IA0972984Medicaid
092250Medicare ID - Type UnspecifiedGRP
E95091Medicare UPIN
IA0972984Medicaid