Healthcare Provider Details

I. General information

NPI: 1316345077
Provider Name (Legal Business Name): ANDREW PETER KRIVOSHIK M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E CENTER AVE
LAKE BLUFF IL
60044-2507
US

IV. Provider business mailing address

421 E CENTER AVE
LAKE BLUFF IL
60044-2507
US

V. Phone/Fax

Practice location:
  • Phone: 847-735-9737
  • Fax:
Mailing address:
  • Phone: 847-735-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1015840
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200200389
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42674
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036111634
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301113666
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number69592-20
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number200200389
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number1015840
License Number StateMA
# 9
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number036111634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: