Basic Information
| Provider Information | |||||||||
| NPI: | 1720236367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN P. NOWICKI M.D. P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2044 BRIDGEPORT AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038740248 | ||||||||
| FaxNumber: | 2038747504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2044 BRIDGEPORT AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038740248 | ||||||||
| FaxNumber: | 2038747504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | NOWICKI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/M.D. | ||||||||
| AuthorizedOfficialTelephone: | 2038740248 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 019703CT | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000384 | 01 | CT | HEALTH NET OF CONNECTICUT | OTHER | 001197037 | 05 | CT | MEDICAID | 010019703CT01 | 01 | CT | ANTHEM BLUE CROSS AND BLUE SHIELD | OTHER |