Provider Demographics
NPI:1487150785
Name:KRIVAN, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:KRIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3239
Mailing Address - Country:US
Mailing Address - Phone:631-353-8818
Mailing Address - Fax:
Practice Address - Street 1:205 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3239
Practice Address - Country:US
Practice Address - Phone:631-353-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCDKSC8727058OtherEMPIRE BLUE CROSS BLUE SHEILD