Provider Demographics
NPI:1427032069
Name:NOVOTNY, STEVEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOHN
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 1:555 REDBIRD CIR
Mailing Address - Street 2:STE 300
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7977
Mailing Address - Country:US
Mailing Address - Phone:920-338-6870
Mailing Address - Fax:
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:STE 300
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39958OtherLICENSE
WI005307355Medicare Oscar/Certification
WI071700029Medicare Oscar/Certification
WI39958OtherLICENSE
WI072900011Medicare Oscar/Certification