Provider Demographics
NPI:1871224493
Name:DIZDAREVIC, BESIM
Entity type:Individual
Prefix:
First Name:BESIM
Middle Name:
Last Name:DIZDAREVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 BRIAN ST
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2625
Mailing Address - Country:US
Mailing Address - Phone:315-601-8959
Mailing Address - Fax:
Practice Address - Street 1:111 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-2517
Practice Address - Country:US
Practice Address - Phone:315-601-8959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant