Healthcare Provider Details

I. General information

NPI: 1104922483
Provider Name (Legal Business Name): MILJAN R STANKOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3564 SCOTTSDALE ST
PORTAGE IN
46368-5420
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax: 219-764-3251
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-3251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number232251
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: