Provider Demographics
NPI:1649381773
Name:NOVACKI, VISNJA (MD)
Entity Type:Individual
Prefix:DR
First Name:VISNJA
Middle Name:
Last Name:NOVACKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HERITAGE WAY NE STE 302
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4544
Mailing Address - Country:US
Mailing Address - Phone:703-771-5100
Mailing Address - Fax:
Practice Address - Street 1:102 HERITAGE WAY NE STE 302
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012226172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
293482OtherAMERIGROUP
000739L12Medicare ID - Type Unspecified