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General NPI Number Information
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NPI Number | 1609440148
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Entity Type | Individual
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Provider Name | BORIS MIOKOVIC MD
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Gender | Male
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Dates
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Enumeration Date | 05/19/2021
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Last Update Date | 05/24/2024
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Provider Practice Location Address
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Address Line | 3333 N SEMINARY ST
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City | GALESBURG
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State | IL
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Zip | 61401-1251
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Country | US
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Telephone | 309-343-5114
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Fax |
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Provider Business Mailing Address
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Address Line | 40 PROSPECT ST., BUILDING 2 APT 2K
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City | NORWALK
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State | CT
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Zip | 06850
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Country | US
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Telephone | 347-656-4595
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036169455
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License Number State | IL
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