Provider Demographics
NPI:1093788465
Name:ILIEVSKI, PETAR MIHAJLO (MD)
Entity Type:Individual
Prefix:DR
First Name:PETAR
Middle Name:MIHAJLO
Last Name:ILIEVSKI
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88211-0629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1112
Practice Address - Country:US
Practice Address - Phone:575-748-8311
Practice Address - Fax:575-736-6352
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29489208800000X
NMMD2011-0017208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0132OtherJOHN DEER
IA0443457Medicaid
IA37336OtherBLUE CROSS /BLUE SHIELD
IAI14058Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IA0443457Medicaid