Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 0101266560 | VA |
Y | 207N00000X | Dermatologist | 2019-00501 | NC |
N | 207N00000X | Dermatologist | ME124757 | FL |
N | 207ND0101X | MOHS-Micrographic Surgeon | 0101266560 | VA |
N | 207ND0101X | MOHS-Micrographic Surgeon | 2019-00501 | NC |
NPI | 1003226051 |
---|---|
Provider Name | Mario Mitkov |
First Address | Winston Salem, NC 27103-1307 |
Second Address | Greensboro, NC 27410-2074 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2014 |
Last Update Date | 09/07/2019 |