Healthcare Provider Details

I. General information

NPI: 1205148244
Provider Name (Legal Business Name): VICTORIA KRAVCHENKO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 10/25/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 E PROSPECT ST
WALDWICK NJ
07463-2008
US

IV. Provider business mailing address

2933 BROADWAY
NEW YORK NY
10025-7801
US

V. Phone/Fax

Practice location:
  • Phone: 917-690-4947
  • Fax:
Mailing address:
  • Phone: 212-662-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007588
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: