Healthcare Provider Details

I. General information

NPI: 1336553874
Provider Name (Legal Business Name): ROMAN IGOREVICH KRIVOCHENITSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVENUE SE STE 130
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

5504 TEQUESTA DR
WEST BLOOMFIELD MI
48323-2356
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-2001
  • Fax: 616-949-8620
Mailing address:
  • Phone: 248-895-9719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDR0061743
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number5859-851
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301105291
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberDR0061743
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number4301105291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: