Provider Demographics
NPI:1093748626
Name:KURJAKOVIC, MENSUD (MD)
Entity Type:Individual
Prefix:DR
First Name:MENSUD
Middle Name:
Last Name:KURJAKOVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 KENNERLY ROAD
Mailing Address - Street 2:STE 364B
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2190
Mailing Address - Country:US
Mailing Address - Phone:314-525-4429
Mailing Address - Fax:314-525-7260
Practice Address - Street 1:10004 KENNERLY RD STE 364B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2190
Practice Address - Country:US
Practice Address - Phone:314-525-4429
Practice Address - Fax:314-525-7260
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201037-12084P0800X
MO20170292212084P0800X
NY2010372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01847456Medicaid
NYG71724Medicare UPIN
NY59M561Medicare ID - Type UnspecifiedEMS PROVIDER NUMBER