Provider Demographics
NPI:1134227598
Name:NOVOTNY, IAN ANTHONY (DPT)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:ANTHONY
Last Name:NOVOTNY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 W SUNSET BLVD
Mailing Address - Street 2:M120
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3701
Mailing Address - Country:US
Mailing Address - Phone:310-246-1050
Mailing Address - Fax:
Practice Address - Street 1:9201 W SUNSET BLVD
Practice Address - Street 2:M120
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3701
Practice Address - Country:US
Practice Address - Phone:310-246-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28753208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28753OtherLICENSE
CA205559183OtherTAX ID