Provider Demographics
NPI:1043265952
Name:KRIVISKY, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:KRIVISKY
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 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:
Practice Address - Street 1:14551 HOPE CENTER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4705
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-936-3099
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME503922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME50392OtherFLORIDA LICENSE
FL046328100Medicaid
0624239OtherAETNA HMO
4129715OtherAETNA PPO
04140OtherBCBS
FLME50392OtherFLORIDA LICENSE
D61025Medicare UPIN
04140ZMedicare PIN