Basic Information
| Provider Information | |||||||||
| NPI: | 1134183023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POPOVICH | ||||||||
| FirstName: | MIODRAG | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5434 W CAPITOL DR | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532162298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148750505 | ||||||||
| FaxNumber: | 4148756786 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W SILVER SPRING DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532094217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144619250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20671-020 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 31569700 | 05 | WI | MEDICAID |