Healthcare Provider Details

I. General information

NPI: 1528359304
Provider Name (Legal Business Name): PETAR VUKASIN M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W EULALIA ST STE 100A
GLENDALE CA
91204-2850
US

IV. Provider business mailing address

222 W. EULALIA ST STE 100A
GLENDALE CA
91204-2508
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-8161
  • Fax: 818-244-5122
Mailing address:
  • Phone: 818-244-8161
  • Fax: 818-244-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG74237
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberG74237
License Number StateCA

VIII. Authorized Official

Name: DR. PETAR VUKASIN
Title or Position: OWNER
Credential: M.D.
Phone: 818-244-8161