Healthcare Provider Details

I. General information

NPI: 1659385516
Provider Name (Legal Business Name): PETAR VUKASIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W EULALIA ST SUITE 100A
GLENDALE CA
91204-2849
US

IV. Provider business mailing address

222 W EULALIA ST SUITE 100A
GLENDALE CA
91204-2849
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberG74237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: