Provider Demographics
NPI:1669449625
Name:VLASIC, NIKSA (MD)
Entity Type:Individual
Prefix:
First Name:NIKSA
Middle Name:
Last Name:VLASIC
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 1:2837 US 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:901 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-1367
Practice Address - Country:US
Practice Address - Phone:906-486-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207073-12085R0202X
MI43010738742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02198052Medicaid
NYG93516Medicare UPIN
NYCC8135Medicare ID - Type Unspecified