Provider Demographics
NPI:1386676914
Name:NOVOTNY, JEROME DOUGLAS JR (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:DOUGLAS
Last Name:NOVOTNY
Suffix:JR
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 1:600 E HURST BLVD
Mailing Address - Street 2:EMPLOYEE HEALTH SERVICES
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-8030
Mailing Address - Country:US
Mailing Address - Phone:817-280-2188
Mailing Address - Fax:817-280-7104
Practice Address - Street 1:600 E HURST BLVD
Practice Address - Street 2:EMPLOYEE HEALTH SERVICES
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-8030
Practice Address - Country:US
Practice Address - Phone:817-280-2188
Practice Address - Fax:817-280-7104
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC19958Medicare UPIN