Healthcare Provider Details

I. General information

NPI: 1275585754
Provider Name (Legal Business Name): MICHAEL K MIOVIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 05/30/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRIMARY CARE 1400 VFW PARKWAY
WEST ROXBURY MA
02132
US

IV. Provider business mailing address

PRIMARY CARE 1400 VFW PARKWAY
WEST ROXBURY MA
02132
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-4025
  • Fax:
Mailing address:
  • Phone: 857-203-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number210144
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: