Healthcare Provider Details

I. General information

NPI: 1518025253
Provider Name (Legal Business Name): KENNETH J KRIVACIC O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7457 LAS COLINAS BLVD #100
IRVING TX
75063-7561
US

IV. Provider business mailing address

7457 LAS COLINAS BLVD #100
IRVING TX
75063-7561
US

V. Phone/Fax

Practice location:
  • Phone: 214-382-3061
  • Fax: 214-382-3071
Mailing address:
  • Phone: 214-382-3061
  • Fax: 214-382-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2928TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2928TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: