Provider Demographics
NPI:1275731010
Name:TONKOVIC-CAPIN, MARIJA (MD)
Entity Type:Individual
Prefix:
First Name:MARIJA
Middle Name:
Last Name:TONKOVIC-CAPIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-2400
Mailing Address - Country:US
Mailing Address - Phone:816-649-3208
Mailing Address - Fax:
Practice Address - Street 1:1600 E EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-2400
Practice Address - Country:US
Practice Address - Phone:816-649-3208
Practice Address - Fax:816-649-3204
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011006615207N00000X, 193200000X
KS94-06648193200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193200000XGroupMulti-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275731010Medicaid
MO785000059Medicare Oscar/Certification