Provider Demographics
NPI:1477229144
Name:JIVOTOVSKI, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:JIVOTOVSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DENNIS LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-1032
Mailing Address - Country:US
Mailing Address - Phone:914-417-1324
Mailing Address - Fax:
Practice Address - Street 1:1200 HIGH RIDGE RD STE 3
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1202
Practice Address - Country:US
Practice Address - Phone:203-359-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9884363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics