Healthcare Provider Details

I. General information

NPI: 1619219946
Provider Name (Legal Business Name): MIRJANA JAKSIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 CHANDELEUR DR
RANCHO PALOS VERDES CA
90275-6371
US

IV. Provider business mailing address

2085 CHANDELEUR DR
RANCHO PALOS VERDES CA
90275-6371
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-7500
  • Fax: 310-831-8740
Mailing address:
  • Phone: 310-519-7500
  • Fax: 310-831-8740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAFE29308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: