Healthcare Provider Details

I. General information

NPI: 1124847926
Provider Name (Legal Business Name): SENIJA MIOCEVIC RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5338 ESTRADE DR
SAN JOSE CA
95118-2922
US

IV. Provider business mailing address

5338 ESTRADE DR
SAN JOSE CA
95118-2922
US

V. Phone/Fax

Practice location:
  • Phone: 408-508-0262
  • Fax:
Mailing address:
  • Phone: 408-508-0262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86343730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: