MEDICARE: DR. DEJAN MATIJEVIC ND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083B0002X	Obesity Medicine (Preventive Medicine) Physician	19787	AZ
2	2083P0901X	Public Health & General Preventive Medicine Physician	19787	AZ
3	2083S0010X	Sports Medicine (Preventive Medicine) Physician	19787	AZ
4	208D00000X	General Practice Physician	19787	AZ
5	175F00000X	Naturopath	19787	AZ

General Provider Information

NPI Number	:	1205497542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEJAN MATIJEVIC ND

Provider Business Mailing Address
First Line	:	1110 E TURNEY AVE APT 5
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-4417
Country	:	US
Telephone Number	:	623-200-7557
Fax Number	:

Provider Business Practice Location Address
First Line	:	6029 N 7TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-1802
Country	:	US
Telephone Number	:	602-252-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	06/26/2019

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