Healthcare Provider Details

I. General information

NPI: 1790072205
Provider Name (Legal Business Name): MITTIE M DRAGOSLJVICH MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BRANSON LANDING BLVD STE 101
BRANSON MO
65616-4055
US

IV. Provider business mailing address

PO BOX 1071
BRANSON MO
65615-1071
US

V. Phone/Fax

Practice location:
  • Phone: 417-348-8032
  • Fax:
Mailing address:
  • Phone: 580-917-5392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2008011533
License Number StateMO

VIII. Authorized Official

Name: DR. MITTIE MATTHEW DRAGOSLJVICH
Title or Position: PHYSICIAN/MANAGER
Credential: M.D.
Phone: 580-917-5392