Healthcare Provider Details

I. General information

NPI: 1255890042
Provider Name (Legal Business Name): NIKOLA KOCOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH ST
PHILADELPHIA PA
19107-4824
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-5050
  • Fax:
Mailing address:
  • Phone: 212-241-6609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD481792
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: