Provider Demographics
NPI:1972685410
Name:IVANCEVIC, NIKOLA (DPM)
Entity Type:Individual
Prefix:DR
First Name:NIKOLA
Middle Name:
Last Name:IVANCEVIC
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5646 ST CHARLES RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BERKELEY
Mailing Address - State:IL
Mailing Address - Zip Code:60163
Mailing Address - Country:US
Mailing Address - Phone:630-782-6557
Mailing Address - Fax:630-782-6559
Practice Address - Street 1:5646 ST CHARLES RD
Practice Address - Street 2:SUITE B
Practice Address - City:BERKELEY
Practice Address - State:IL
Practice Address - Zip Code:60163
Practice Address - Country:US
Practice Address - Phone:630-782-6557
Practice Address - Fax:630-782-6559
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004831213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-004831Medicaid
IL016-004831Medicaid
ILU73434Medicare UPIN