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General NPI Number Information
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NPI Number | 1013191287
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Entity Type | Organization
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Legal Business Name | NIKOLA IVANCEVIC DPM PC
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Dates
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Enumeration Date | 12/24/2007
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 135 S PALMER DR SUITE 105
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City | ELMHURST
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State | IL
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Zip | 60126-3403
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Country | US
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Telephone | 630-782-6557
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Fax | 630-782-6559
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Provider Business Mailing Address
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Address Line | 1630 VICTORIA AVE
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City | BERKELEY
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State | IL
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Zip | 60163-1467
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Country | US
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Telephone | 630-782-6557
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Fax | 630-782-6559
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Authorized Official
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Title or Position | PODIATRIST
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Name | NIKOLA IVANCEVIC
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Credential | DPM
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Telephone | 630-782-6557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 016-004831
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License Number State | IL
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