Provider Demographics
NPI:1790072205
Name:MITTIE M DRAGOSLJVICH MD LLC
Entity Type:Organization
Organization Name:MITTIE M DRAGOSLJVICH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITTIE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DRAGOSLJVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-917-5392
Mailing Address - Street 1:PO BOX 1071
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65615-1071
Mailing Address - Country:US
Mailing Address - Phone:580-917-5392
Mailing Address - Fax:
Practice Address - Street 1:545 BRANSON LANDING BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4055
Practice Address - Country:US
Practice Address - Phone:417-348-8032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008011533174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100025090AMedicaid
OK731377294001OtherBC/BS OF OKLAHOMA
OK731377294001OtherBC/BS OF OKLAHOMA