Provider Demographics
NPI:1639421324
Name:MIRKOVIC, JELENA (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:JELENA
Middle Name:
Last Name:MIRKOVIC
Suffix:
Gender:F
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 KNAPP STEET
Mailing Address - Street 2:#302
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-335-4017
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:BRIGHAM AND WOMENS'S HOSPITAL DEPARTMENT OF PATHOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-335-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA249217207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100324921OtherBRIGHAM AND WOMEN'S HOSPITAL EMPLOYEE ID NUMBER