Basic Information
| Provider Information | |||||||||
| NPI: | 1851374078 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NOVOTNY | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 SAND POINT WAY NE | ||||||||
| Address2: | SUITE 100, M/S CUMG, PO BOX 359300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069878540 | ||||||||
| FaxNumber: | 2069878415 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | NEUROLOGY, M/S B-5552 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872078 | ||||||||
| FaxNumber: | 2069872649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | MD60078540 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0600X | MD60078540 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 0008549560 | 05 | WA | MEDICAID | 001285578 | 05 | CT | MEDICAID |