Healthcare Provider Details

I. General information

NPI: 1063107720
Provider Name (Legal Business Name): BRANDON NOVATKO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11232 LITTLE RIVER WAY
PARRISH FL
34219-2116
US

IV. Provider business mailing address

11232 LITTLE RIVER WAY
PARRISH FL
34219-2116
US

V. Phone/Fax

Practice location:
  • Phone: 813-469-8693
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS22738
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: