Provider Demographics
NPI:1598487597
Name:GOSTIMIR, MISO (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MISO
Middle Name:
Last Name:GOSTIMIR
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WALNUT ST STE 930
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3130
Mailing Address - Fax:
Practice Address - Street 1:840 WALNUT ST STE 930
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5599
Practice Address - Country:US
Practice Address - Phone:215-928-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD476883207WX0109X, 207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery