Provider Demographics
NPI:1770772725
Name:KRIVONYAK, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:KRIVONYAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E. DIXIE AVENUE
Mailing Address - Street 2:ATTN: CREDENTIALING, NORTH CAMPUS
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-323-4267
Mailing Address - Fax:352-323-5039
Practice Address - Street 1:550 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:352-323-2273
Practice Address - Fax:352-323-2261
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1019152083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME101915OtherMEDICAL LICENSE
FLME101915OtherMEDICAL LICENSE