Provider Demographics
NPI:1558343210
Name:NESIN, MIRJANA (MD)
Entity Type:Individual
Prefix:
First Name:MIRJANA
Middle Name:
Last Name:NESIN
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 1:104 GEDNEY ST
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2236
Mailing Address - Country:US
Mailing Address - Phone:845-376-2381
Mailing Address - Fax:
Practice Address - Street 1:104 GEDNEY ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2236
Practice Address - Country:US
Practice Address - Phone:845-376-2481
Practice Address - Fax:845-376-2381
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223707208000000X, 2080N0001X
NY1787212080N0001X, 208000000X
MDD0065130208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2106914Medicaid
MA2106914Medicaid
H06608Medicare UPIN