Provider Demographics
NPI:1710908934
Name:MIRIC, SLOBODAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:SLOBODAN
Middle Name:J
Last Name:MIRIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 W MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2174
Mailing Address - Country:US
Mailing Address - Phone:973-625-0858
Mailing Address - Fax:973-625-0859
Practice Address - Street 1:35 W MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2174
Practice Address - Country:US
Practice Address - Phone:973-625-0858
Practice Address - Fax:973-625-0859
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA083809002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101772589 001Medicaid
NJ0163732Medicaid
PA105038PUMMedicare ID - Type Unspecified
NJ0163732Medicaid
PA101772589 001Medicaid