Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 4301098347 | MI |
NPI | 1003109216 |
---|---|
Provider Name | Nikolas Dimovski |
First Address | Shelby Township, MI 48315-1826 |
Second Address | Shelby Township, MI 48315-4401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2011 |
Last Update Date | 06/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0503044 | BCBS INDIVIDUAL PIN (01) | MI |
700E031610 | BCBSM GROUP PIN (01) | MI |