Provider Demographics
NPI:1134284904
Name:NOWOTNY, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:NOWOTNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10805 SUNSET OFFICE DRIVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127
Mailing Address - Country:US
Mailing Address - Phone:314-909-8484
Mailing Address - Fax:314-909-8485
Practice Address - Street 1:10805 SUNSET OFFICE DRIVE
Practice Address - Street 2:SUITE 401
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127
Practice Address - Country:US
Practice Address - Phone:314-909-8484
Practice Address - Fax:314-909-8485
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO369402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E50259Medicare UPIN