Healthcare Provider Details

I. General information

NPI: 1609440148
Provider Name (Legal Business Name): BORIS MIOKOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date: 11/03/2022
Reactivation Date: 02/15/2023

III. Provider practice location address

3333 N SEMINARY ST
GALESBURG IL
61401-1251
US

IV. Provider business mailing address

40 PROSPECT ST., BUILDING 2 APT 2K
NORWALK CT
06850
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-5114
  • Fax:
Mailing address:
  • Phone: 347-656-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036169455
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: