Healthcare Provider Details

I. General information

NPI: 1457332272
Provider Name (Legal Business Name): NORMAN NOVELLY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax: 505-368-7011
Mailing address:
  • Phone: 505-368-6001
  • Fax: 505-368-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number040500
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number040500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: