1750452801 NPI number — DR. KSENIJA MODRIC JEDNACAK M.D.

Table of content: DR. KSENIJA MODRIC JEDNACAK M.D. (NPI 1750452801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750452801 NPI number — DR. KSENIJA MODRIC JEDNACAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODRIC JEDNACAK
Provider First Name:
KSENIJA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MODRIC
Provider Other First Name:
KSENIJA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750452801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6726 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53213-3254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-774-4074
Provider Business Mailing Address Fax Number:
414-774-0471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6726 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53213-3254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-774-4074
Provider Business Practice Location Address Fax Number:
414-774-0471
Provider Enumeration Date:
11/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  47908-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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