Provider Demographics
NPI:1851374078
Name:NOVOTNY, EDWARD J JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:NOVOTNY
Suffix:JR
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 1:4500 SAND POINT WAY NE
Mailing Address - Street 2:SUITE 100, M/S CUMG, PO BOX 359300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3900
Mailing Address - Country:US
Mailing Address - Phone:206-987-8540
Mailing Address - Fax:206-987-8415
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:NEUROLOGY, M/S B-5552
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2078
Practice Address - Fax:206-987-2649
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD600785402084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0008549560Medicaid
CT001285578Medicaid
D88805Medicare UPIN
CT001285578Medicaid