Provider Demographics
NPI:1336553874
Name:KRIVOCHENITSER, ROMAN IGOREVICH (MD)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:IGOREVICH
Last Name:KRIVOCHENITSER
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 1:5504 TEQUESTA DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2356
Mailing Address - Country:US
Mailing Address - Phone:248-895-9719
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVENUE SE
Practice Address - Street 2:STE 130
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-949-2001
Practice Address - Fax:616-949-8620
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0061743207W00000X, 207WX0009X
WI5859-851207W00000X
MI4301105291207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology