Provider Demographics
NPI:1063574176
Name:NOVOTNY, MARK M (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:NOVOTNY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:535 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3772
Mailing Address - Country:US
Mailing Address - Phone:770-534-1711
Mailing Address - Fax:
Practice Address - Street 1:535 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3772
Practice Address - Country:US
Practice Address - Phone:770-534-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00922501AMedicaid
GAU86000Medicare UPIN
GA41ZCDWSMedicare ID - Type Unspecified