Healthcare Provider Details

I. General information

NPI: 1457326266
Provider Name (Legal Business Name): LIDIJA PETROVIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SAN PABLO ST FL 6
LOS ANGELES CA
90033-5320
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-4815
  • Fax:
Mailing address:
  • Phone: 323-442-2582
  • Fax: 323-442-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number226218
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberA52273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: