=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184707564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL BARRY KRIVITSKY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 04/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 ACADEMY ST
-----------------------------------------------------
City | PRESQUE ISLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04769-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-768-4382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 THIRD ST
-----------------------------------------------------
City | PRESQUE ISLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-267-6185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G40102
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | MD20832
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------