Provider Demographics
NPI:1164983250
Name:NOVOTNY, JOHN J (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:NOVOTNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 IVY ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1627
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2071
Practice Address - Street 1:200 MADISON AVE STE 1A
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3219
Practice Address - Country:US
Practice Address - Phone:607-734-4110
Practice Address - Fax:607-733-3357
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334152208000000X, 207XX0005X
LA3390372080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490612Medicaid