Provider Demographics
NPI: | 1457332272 |
---|---|
Name: | NOVELLY, NORMAN (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | NORMAN |
Middle Name: | |
Last Name: | NOVELLY |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 160 |
Mailing Address - Street 2: | |
Mailing Address - City: | SHIPROCK |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87420-0160 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-368-6001 |
Mailing Address - Fax: | 505-368-7011 |
Practice Address - Street 1: | US HWY 491 NORTH |
Practice Address - Street 2: | |
Practice Address - City: | SHIPROCK |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87420 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-368-6001 |
Practice Address - Fax: | 505-368-7011 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-09 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 040500 | 207YP0228X, 207Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | |
No | 207YP0228X | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 00669721E | Medicaid | |
GA | AN2126515 | Other | DEA |
GA | 04BDBNK | Medicare ID - Type Unspecified | |
GA | 00669721E | Medicaid |