Healthcare Provider Details

I. General information

NPI: 1245796846
Provider Name (Legal Business Name): MIROSLAV L DJORDJEVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MADISON AVE FL 6
NEW YORK NY
10029-6514
US

IV. Provider business mailing address

1425 MADISON AVE FL 6
NEW YORK NY
10029-6514
US

V. Phone/Fax

Practice location:
  • Phone: 212-659-5559
  • Fax:
Mailing address:
  • Phone: 212-659-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number293365
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: