Provider Demographics
NPI:1609440148
Name:MIOKOVIC, BORIS (MD)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:MIOKOVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PROSPECT ST., BUILDING 2 APT 2K
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850
Mailing Address - Country:US
Mailing Address - Phone:347-656-4595
Mailing Address - Fax:
Practice Address - Street 1:3333 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-343-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2024-05-24
Deactivation Date:2022-11-03
Deactivation Code:
Reactivation Date:2023-02-15
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036169455207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program