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General NPI Number Information
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NPI Number | 1790072205
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Entity Type | Organization
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Legal Business Name | MITTIE M DRAGOSLJVICH MD LLC
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Dates
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Enumeration Date | 07/05/2011
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Last Update Date | 07/05/2011
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Provider Practice Location Address
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Address Line | 545 BRANSON LANDING BLVD STE 101
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City | BRANSON
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State | MO
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Zip | 65616-4055
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Country | US
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Telephone | 417-348-8032
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1071
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City | BRANSON
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State | MO
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Zip | 65615-1071
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Country | US
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Telephone | 580-917-5392
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/MANAGER
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Name | DR. MITTIE MATTHEW DRAGOSLJVICH
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Credential | M.D.
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Telephone | 580-917-5392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2008011533
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License Number State | MO
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