Provider Demographics
NPI:1730142639
Name:MITROVIC, JOHN (PT SCS ATC CSCS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MITROVIC
Suffix:
Gender:M
Credentials:PT SCS ATC CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:4125 IRONBOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2666
Practice Address - Country:US
Practice Address - Phone:757-220-8383
Practice Address - Fax:757-253-7833
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8928649Medicaid
VA192935OtherBCBS PHYSICAL THERAPY
4460951OtherAETNA
VA650003973OtherRAILROAD MEDICARE
4460951OtherAETNA
VA650000210Medicare PIN