Healthcare Provider Details

I. General information

NPI: 1245688191
Provider Name (Legal Business Name): VASILIJE MIJOVIC M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RETREAT AVE STE 900
HARTFORD CT
06106-2553
US

IV. Provider business mailing address

100 RETREAT AVE STE 900
HARTFORD CT
06106-2553
US

V. Phone/Fax

Practice location:
  • Phone: 860-218-2204
  • Fax: 860-461-0224
Mailing address:
  • Phone: 860-218-2204
  • Fax: 860-461-0224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number66764
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: