Basic Information
| Provider Information | |||||||||
| NPI: | 1093748626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KURJAKOVIC | ||||||||
| FirstName: | MENSUD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10004 KENNERLY ROAD | ||||||||
| Address2: | STE 364B | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD STE 364B | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 201037-1 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2017029221 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01847456 | 05 | NY | MEDICAID |