1386676914 NPI number — JEROME DOUGLAS NOVOTNY JR. M.D.

Table of content: JEROME DOUGLAS NOVOTNY JR. M.D. (NPI 1386676914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386676914 NPI number — JEROME DOUGLAS NOVOTNY JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVOTNY
Provider First Name:
JEROME
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386676914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 E HURST BLVD
Provider Second Line Business Mailing Address:
EMPLOYEE HEALTH SERVICES
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76053-8030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-280-2188
Provider Business Mailing Address Fax Number:
817-280-7104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 E HURST BLVD
Provider Second Line Business Practice Location Address:
EMPLOYEE HEALTH SERVICES
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76053-8030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-280-2188
Provider Business Practice Location Address Fax Number:
817-280-7104
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G5436 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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