Provider Demographics
NPI:1518025253
Name:KRIVACIC, KENNETH J (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:KRIVACIC
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7457 LAS COLINAS BLVD
Mailing Address - Street 2:#100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-7561
Mailing Address - Country:US
Mailing Address - Phone:214-382-3061
Mailing Address - Fax:214-382-3071
Practice Address - Street 1:7457 LAS COLINAS BLVD
Practice Address - Street 2:#100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7561
Practice Address - Country:US
Practice Address - Phone:214-382-3061
Practice Address - Fax:214-382-3071
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2928TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT14271Medicare UPIN
TXT14271Medicare UPIN