Basic Information
| Provider Information | |||||||||
| NPI: | 1841286408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIVITSKI | ||||||||
| FirstName: | ANDREJ | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 DOCTORS CT | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347487314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678311 | ||||||||
| FaxNumber: | 3526225771 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 DOCTORS CT | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347487314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527879838 | ||||||||
| FaxNumber: | 3527878705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C10006841 | DE | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME119527 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 014042100 | 05 | FL | MEDICAID | 14Z03 | 01 | FL | BCBS | OTHER |