Provider Demographics
NPI:1225483563
Name:NOVOTNY, LEESA RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEESA
Middle Name:RAE
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEESA
Other - Middle Name:RAE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:824 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265
Mailing Address - Country:US
Mailing Address - Phone:320-269-8877
Mailing Address - Fax:320-269-8186
Practice Address - Street 1:824 N 11TH ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265
Practice Address - Country:US
Practice Address - Phone:320-269-8877
Practice Address - Fax:320-269-8186
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-24
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine