Provider Demographics
NPI:1033175039
Name:S E NOWOTNY DO PA
Entity type:Organization
Organization Name:S E NOWOTNY DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:NOWOTNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-929-6960
Mailing Address - Street 1:PO BOX 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-371-8376
Practice Address - Street 1:5607 EVERHART RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4904
Practice Address - Country:US
Practice Address - Phone:361-854-4601
Practice Address - Fax:361-371-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154960202Medicaid
TXH51346Medicare UPIN
TX00275UMedicare PIN