Provider Demographics
NPI:1255396206
Name:MIJATOVIC, LJILJANA (MD)
Entity type:Individual
Prefix:
First Name:LJILJANA
Middle Name:
Last Name:MIJATOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BRYANT ST.
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222
Mailing Address - Country:US
Mailing Address - Phone:716-878-7701
Mailing Address - Fax:716-878-7316
Practice Address - Street 1:219 BRYANT ST.
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222
Practice Address - Country:US
Practice Address - Phone:716-878-7701
Practice Address - Fax:716-878-7701
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002096-1207L00000X
NY246884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02869309Medicaid
NY02869309Medicaid
RB0152Medicare UPIN