Basic Information
| Provider Information | |||||||||
| NPI: | 1538337282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THOMAS P NOWAK MD PHD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827 | ||||||||
| Address2: | |||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920750827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585131833 | ||||||||
| FaxNumber: | 8585131838 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S SIERRA AVE | ||||||||
| Address2: | #109 | ||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583576953 | ||||||||
| FaxNumber: | 8585131838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | NOWAK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8583576953 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | G59443 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G594430 | 05 | CA | MEDICAID |