Provider Demographics
NPI:1588765317
Name:NIKOLOV, BORISLAV M (MD)
Entity type:Individual
Prefix:
First Name:BORISLAV
Middle Name:M
Last Name:NIKOLOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W WILSON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3678
Mailing Address - Country:US
Mailing Address - Phone:717-969-0051
Mailing Address - Fax:
Practice Address - Street 1:2450 W WILSON AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3678
Practice Address - Country:US
Practice Address - Phone:717-969-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361032832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103283Medicaid
364271985-23OtherJOHN DEERE
10593690OtherCAQH
4815127OtherBC/BS
364271985-23OtherJOHN DEERE
530390Medicare ID - Type Unspecified
4815127OtherBC/BS