Provider Demographics
NPI:1649388026
Name:ZOTOVIC, MIROSLAV BOSCO (MD)
Entity Type:Individual
Prefix:
First Name:MIROSLAV
Middle Name:BOSCO
Last Name:ZOTOVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S GULPH RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-643-1090
Mailing Address - Fax:803-643-8080
Practice Address - Street 1:68 PHYSICIAN DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6388
Practice Address - Country:US
Practice Address - Phone:803-643-1090
Practice Address - Fax:803-643-8080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19863207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT39882Medicaid
SCG627275836Medicare ID - Type Unspecified
SCG62727Medicare UPIN