Provider Demographics
NPI:1275585754
Name:MIOVIC, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:MIOVIC
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:PRIMARY CARE
Mailing Address - Street 2:1400 VFW PARKWAY
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132
Mailing Address - Country:US
Mailing Address - Phone:857-203-4025
Mailing Address - Fax:
Practice Address - Street 1:PRIMARY CARE
Practice Address - Street 2:1400 VFW PARKWAY
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:857-203-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2101442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110004643/AMedicaid
A3329001Medicare PIN