Provider Demographics
NPI:1487210217
Name:BILANOVIC, MIRJANA
Entity Type:Individual
Prefix:
First Name:MIRJANA
Middle Name:
Last Name:BILANOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6944 18TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6550
Mailing Address - Country:US
Mailing Address - Phone:727-686-6479
Mailing Address - Fax:
Practice Address - Street 1:6944 18TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6550
Practice Address - Country:US
Practice Address - Phone:727-686-6479
Practice Address - Fax:727-374-4375
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687551396Medicaid