Healthcare Provider Details

I. General information

NPI: 1114243805
Provider Name (Legal Business Name): ANNA KRAVTSOV D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HAMBURG TPKE STE 302
WAYNE NJ
07470-2139
US

IV. Provider business mailing address

2100 LINWOOD AVE APT 9N
FORT LEE NJ
07024-3130
US

V. Phone/Fax

Practice location:
  • Phone: 973-790-9222
  • Fax:
Mailing address:
  • Phone: 201-341-1605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number270608
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number62969
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MB09435000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: