Provider Demographics
NPI:1508029042
Name:SCOPULOVIC-NIKOLIC, BILJANA
Entity Type:Individual
Prefix:MRS
First Name:BILJANA
Middle Name:
Last Name:SCOPULOVIC-NIKOLIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BILJANA
Other - Middle Name:
Other - Last Name:SCOPULOVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8100 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4254
Mailing Address - Country:US
Mailing Address - Phone:201-866-6770
Mailing Address - Fax:201-866-6771
Practice Address - Street 1:8100 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4254
Practice Address - Country:US
Practice Address - Phone:201-866-6770
Practice Address - Fax:201-866-6771
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09337000207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0430421Medicaid
NJ0430421Medicaid