Provider Demographics
NPI:1093776445
Name:NOVELLI, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:NOVELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:J
Other - Last Name:NOVELLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2731 TRANSIT RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9039
Mailing Address - Country:US
Mailing Address - Phone:716-677-4178
Mailing Address - Fax:855-816-9607
Practice Address - Street 1:2731 TRANSIT RD STE 107
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059-9039
Practice Address - Country:US
Practice Address - Phone:716-677-4178
Practice Address - Fax:855-816-9607
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128300-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00617294Medicaid
NY128300-1OtherLICENSE
NY33D0949004OtherCLIA
NY16-1172119OtherTAX ID
NY16-1172119OtherTAX ID
NY00617294Medicaid
NY16-1172119OtherTAX ID
NYAN9160451OtherDEA