Healthcare Provider Details

I. General information

NPI: 1215334644
Provider Name (Legal Business Name): JOVANKA ZIVKOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3013 STEINWAY ST
ASTORIA NY
11103-3456
US

IV. Provider business mailing address

3013 STEINWAY ST # 2R
ASTORIA NY
11103-3456
US

V. Phone/Fax

Practice location:
  • Phone: 718-701-1225
  • Fax: 718-701-1265
Mailing address:
  • Phone: 718-701-1225
  • Fax: 718-701-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number058354
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: