Provider Demographics
NPI:1497154710
Name:MALOVIC, MIRKO
Entity Type:Individual
Prefix:
First Name:MIRKO
Middle Name:
Last Name:MALOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21225 KELLY RD
Mailing Address - Street 2:SUITE # 8
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021
Mailing Address - Country:US
Mailing Address - Phone:586-859-7371
Mailing Address - Fax:208-694-4279
Practice Address - Street 1:21225 KELLY RD
Practice Address - Street 2:SUITE # 8
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-859-7371
Practice Address - Fax:208-694-4279
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501003414237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist