Basic Information
Provider Information
NPI: 1104028604
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LITRIVIS
FirstName: EVGENIA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1 GUSTAVE L LEVY PL
Address2: #1070
City: NEW YORK
State: NY
PostalCode: 100296500
CountryCode: US
TelephoneNumber: 2122415561
FaxNumber: 2128609737
Practice Location
Address1: 1440 MADISON AVE
Address2:  
City: NEW YORK
State: NY
PostalCode: 100296508
CountryCode: US
TelephoneNumber: 2126598552
FaxNumber: 2128609737
Other Information
ProviderEnumerationDate: 06/05/2007
LastUpdateDate: 11/14/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0300X234576-1NYY Allopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
207RH0002X234576-1NYN Allopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine

ID Information
IDTypeStateIssuerDescription
0298556405NY MEDICAID


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