Provider Demographics
NPI:1053362186
Name:NOVAK, DIANA LYNN (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9200
Mailing Address - Country:US
Mailing Address - Phone:231-947-0404
Mailing Address - Fax:231-947-2190
Practice Address - Street 1:3960 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9200
Practice Address - Country:US
Practice Address - Phone:231-947-0404
Practice Address - Fax:231-947-2190
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076485207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5271015Medicaid
11301109OtherCAQH
MI5271015Medicaid