Healthcare Provider Details

I. General information

NPI: 1962791053
Provider Name (Legal Business Name): DANIELA MICIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 213-840-8284
  • Fax:
Mailing address:
  • Phone: 626-204-6747
  • Fax: 626-396-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA122430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: