Provider Demographics
NPI:1295844777
Name:NOVOTNY, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:NOVOTNY
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 1:36855 AMERICAN WAY
Mailing Address - Street 2:2D
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-4045
Mailing Address - Country:US
Mailing Address - Phone:440-934-2770
Mailing Address - Fax:440-934-2774
Practice Address - Street 1:36855 AMERICAN WAY
Practice Address - Street 2:2D
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-4045
Practice Address - Country:US
Practice Address - Phone:440-934-2770
Practice Address - Fax:440-934-2774
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-8990-N174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179337Medicaid
OHG06255Medicare UPIN
OH0179337Medicaid