Healthcare Provider Details

I. General information

NPI: 1083611602
Provider Name (Legal Business Name): GORDANA STEVANOVIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13112 EVENING CREEK DR S
SAN DIEGO CA
92128-4108
US

IV. Provider business mailing address

2374 E PACIFICA PL
RANCHO DOMINGUEZ CA
90220-6214
US

V. Phone/Fax

Practice location:
  • Phone: 818-858-4390
  • Fax: 310-698-7054
Mailing address:
  • Phone: 310-225-3244
  • Fax: 310-698-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA48595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: