=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669633129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERGEY P LITVINOV M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2008
-----------------------------------------------------
Last Update Date | 08/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2215 N MILITARY TRL STE B
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-932-4665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 LESLIE DR
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-362-7570
-----------------------------------------------------
Fax | 954-362-7559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME101966
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------