Healthcare Provider Details

I. General information

NPI: 1669449625
Provider Name (Legal Business Name): NIKSA VLASIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LAKESHORE DR
ISHPEMING MI
49849-1367
US

IV. Provider business mailing address

2837 US 41 W
MARQUETTE MI
49855-2252
US

V. Phone/Fax

Practice location:
  • Phone: 906-486-4431
  • Fax:
Mailing address:
  • Phone: 906-225-3964
  • Fax: 906-226-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number207073-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301073874
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: