Provider Demographics
NPI:1073154506
Name:DIZDAREVIC, BOJAN
Entity Type:Individual
Prefix:
First Name:BOJAN
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 1:1502 BETTE RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-2208
Mailing Address - Country:US
Mailing Address - Phone:315-327-6469
Mailing Address - Fax:
Practice Address - Street 1:1502 BETTE RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-2208
Practice Address - Country:US
Practice Address - Phone:315-327-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY753086163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse