Basic Information
Provider Information
NPI: 1003017443
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLOKAR
FirstName: MIRJANA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 65 BLEECKER ST
Address2: 12TH FLOOR
City: NEW YORK
State: NY
PostalCode: 100122420
CountryCode: US
TelephoneNumber: 2125052652
FaxNumber:  
Practice Location
Address1: 65 BLEECKER ST
Address2: 12TH FLOOR
City: NEW YORK
State: NY
PostalCode: 100122420
CountryCode: US
TelephoneNumber: 2125052652
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/31/2007
LastUpdateDate: 03/27/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
102L00000X137190NYY Behavioral Health & Social Service ProvidersPsychoanalyst 

ID Information
IDTypeStateIssuerDescription
0036794605NY MEDICAID


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