Provider Demographics
NPI:1699044362
Name:NOVOTNY, ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
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 1:405 WEST RAVINWOODS ROAD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1366
Mailing Address - Country:US
Mailing Address - Phone:309-691-0794
Mailing Address - Fax:
Practice Address - Street 1:405 W RAVINWOODS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1366
Practice Address - Country:US
Practice Address - Phone:309-691-0794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-030309207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery