Provider Demographics
NPI:1235525650
Name:NOVACK, MARISSA (MD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:NOVACK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 MEDICAL PARK RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8529
Mailing Address - Country:US
Mailing Address - Phone:704-660-4584
Mailing Address - Fax:
Practice Address - Street 1:146 MEDICAL PARK RD STE 202
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8529
Practice Address - Country:US
Practice Address - Phone:704-660-4584
Practice Address - Fax:704-660-4967
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308402208600000X, 208600000X
NC2025-00277208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty