Healthcare Provider Details

I. General information

NPI: 1205497542
Provider Name (Legal Business Name): DEJAN MATIJEVIC ND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6029 N 7TH ST
PHOENIX AZ
85014-1802
US

IV. Provider business mailing address

1110 E TURNEY AVE APT 5
PHOENIX AZ
85014-4417
US

V. Phone/Fax

Practice location:
  • Phone: 602-252-6000
  • Fax:
Mailing address:
  • Phone: 623-200-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number19787
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number19787
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number19787
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number19787
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number19787
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: