Healthcare Provider Details

I. General information

NPI: 1598487597
Provider Name (Legal Business Name): MISO GOSTIMIR MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WALNUT ST STE 930
PHILADELPHIA PA
19107-5599
US

IV. Provider business mailing address

840 WALNUT ST STE 930
PHILADELPHIA PA
19107-5109
US

V. Phone/Fax

Practice location:
  • Phone: 215-928-3130
  • Fax:
Mailing address:
  • Phone: 215-928-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberMD476883
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberMD476883
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD476883
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: