Healthcare Provider Details

I. General information

NPI: 1093788465
Provider Name (Legal Business Name): PETAR MIHAJLO ILIEVSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N 13TH ST
ARTESIA NM
88210-1112
US

IV. Provider business mailing address

PO BOX 629
ARTESIA NM
88211-0629
US

V. Phone/Fax

Practice location:
  • Phone: 575-748-8311
  • Fax: 575-736-6352
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number29489
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD2011-0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: