Provider Demographics
NPI:1427199256
Name:WILLIAM J. NOVELLI, JR., MD, PA
Entity Type:Organization
Organization Name:WILLIAM J. NOVELLI, JR., MD, PA
Other - Org Name:WELLFAST HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:409-722-9355
Mailing Address - Street 1:1509 S HWY 69
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627
Mailing Address - Country:US
Mailing Address - Phone:409-722-9355
Mailing Address - Fax:409-420-1002
Practice Address - Street 1:1509 S HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-7807
Practice Address - Country:US
Practice Address - Phone:409-722-9355
Practice Address - Fax:409-420-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167908601Medicaid
TX167908601Medicaid