Provider Demographics
NPI:1720107246
Name:ROBERTO NOVOA, M.D., LLC
Entity Type:Organization
Organization Name:ROBERTO NOVOA, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-363-1341
Mailing Address - Street 1:2600 SIXTH STREET SW
Mailing Address - Street 2:SUITE A2-110
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-0329
Mailing Address - Country:US
Mailing Address - Phone:330-363-1341
Mailing Address - Fax:330-363-0074
Practice Address - Street 1:2600 6TH ST SW
Practice Address - Street 2:BUILDING A, STE A2-110
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-363-1341
Practice Address - Fax:330-363-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0791353Medicaid
OHD08750Medicare UPIN
OH0791353Medicaid