Provider Demographics
NPI:1922369693
Name:KOZHIN-REVICH, JENNIFER (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KOZHIN-REVICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E 21ST ST
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6212
Mailing Address - Country:US
Mailing Address - Phone:212-530-0659
Mailing Address - Fax:212-867-4353
Practice Address - Street 1:35 E 21ST ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6212
Practice Address - Country:US
Practice Address - Phone:212-530-0659
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY272971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program