Healthcare Provider Details

I. General information

NPI: 1780688192
Provider Name (Legal Business Name): VIVIAN AKRIVE KOMINOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 05/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W MAIN ST STE 205 CN5050
FREEHOLD NJ
07728-2537
US

IV. Provider business mailing address

901 W MAIN ST STE 205 CN 5050
FREEHOLD NJ
07728-2537
US

V. Phone/Fax

Practice location:
  • Phone: 732-866-0800
  • Fax: 732-866-0018
Mailing address:
  • Phone: 732-866-0800
  • Fax: 732-866-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA46965
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: