Provider Demographics
NPI:1053607416
Name:IVANAVICIENE, JURATE (MD)
Entity type:Individual
Prefix:MRS
First Name:JURATE
Middle Name:
Last Name:IVANAVICIENE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5301
Mailing Address - Country:US
Mailing Address - Phone:475-210-4499
Mailing Address - Fax:203-382-2114
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4292
Practice Address - Country:US
Practice Address - Phone:475-210-4499
Practice Address - Fax:203-382-2114
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT055544207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program