Provider Demographics
NPI:1407869241
Name:NIKOLIC, BORIS (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:NIKOLIC
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 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060
Mailing Address - Country:US
Mailing Address - Phone:413-582-2554
Mailing Address - Fax:413-582-4779
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2554
Practice Address - Fax:413-582-4779
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2339822085B0100X, 2085N0700X, 2085N0904X, 2085R0202X, 2085R0204X, 2085U0001X
PAMD4292362085R0204X
GA524732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110072175AMedicaid
PA101888735Medicaid