1770772725 NPI number — GREGORY S KRIVONYAK M.D.

Table of content: GREGORY S KRIVONYAK M.D. (NPI 1770772725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770772725 NPI number — GREGORY S KRIVONYAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRIVONYAK
Provider First Name:
GREGORY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770772725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 E. DIXIE AVENUE
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING, NORTH CAMPUS
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-323-4267
Provider Business Mailing Address Fax Number:
352-323-5039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 E DIXIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-323-2273
Provider Business Practice Location Address Fax Number:
352-323-2261
Provider Enumeration Date:
10/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0500X , with the licence number:  ME 101915 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ME101915 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 115316300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com