1215190186 NPI number — MR. MIODRAG MILOVANOVIC

Table of content: MR. MIODRAG MILOVANOVIC (NPI 1215190186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215190186 NPI number — MR. MIODRAG MILOVANOVIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILOVANOVIC
Provider First Name:
MIODRAG
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215190186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
146 CLIFTON ST.
Provider Second Line Business Mailing Address:
UNIT 10
Provider Business Mailing Address City Name:
MALDEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02148-2579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-230-2556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 MAIN ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
WALTHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-893-2003
Provider Business Practice Location Address Fax Number:
781-647-0183
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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