Provider Demographics
NPI:1013191287
Name:NIKOLA IVANCEVIC DPM PC
Entity Type:Organization
Organization Name:NIKOLA IVANCEVIC DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:IVANCEVIC
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-782-6557
Mailing Address - Street 1:1630 VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:IL
Mailing Address - Zip Code:60163-1467
Mailing Address - Country:US
Mailing Address - Phone:630-782-6557
Mailing Address - Fax:630-782-6559
Practice Address - Street 1:135 S PALMER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3403
Practice Address - Country:US
Practice Address - Phone:630-782-6557
Practice Address - Fax:630-782-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004831213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480027618OtherMEDICARE RAILROAD PIN
IL016-004831Medicaid
IL213034Medicare PIN
IL016-004831Medicaid
IL5448760001Medicare NSC