Provider Demographics
NPI:1265826804
Name:BARJAKTAROVICH, NICHOLAS TYLER (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:TYLER
Last Name:BARJAKTAROVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30550 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-1528
Mailing Address - Country:US
Mailing Address - Phone:586-771-0290
Mailing Address - Fax:586-771-5450
Practice Address - Street 1:30550 UTICA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-1528
Practice Address - Country:US
Practice Address - Phone:586-771-0290
Practice Address - Fax:586-771-5450
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101021847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program