Provider Demographics
NPI:1699852962
Name:NOVOSELAC, AMORY VEDRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMORY
Middle Name:VEDRAN
Last Name:NOVOSELAC
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 1:12 E 86TH ST
Mailing Address - Street 2:OFC 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0506
Mailing Address - Country:US
Mailing Address - Phone:212-861-6660
Mailing Address - Fax:212-744-4696
Practice Address - Street 1:12 E 86TH ST
Practice Address - Street 2:OFC 4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0506
Practice Address - Country:US
Practice Address - Phone:212-861-6660
Practice Address - Fax:212-744-4696
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252245207RH0003X
OH35084949207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2589739Medicaid
KY64102163Medicaid
KY64102163Medicaid
OHI35467Medicare UPIN