Healthcare Provider Details

I. General information

NPI: 1124012372
Provider Name (Legal Business Name): LJILJANA PLISIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 MAIN ST
BRANFORD CT
06405-3612
US

IV. Provider business mailing address

64-1 ROUTE 80
KILLINGWORTH CT
06419-1465
US

V. Phone/Fax

Practice location:
  • Phone: 203-488-8306
  • Fax: 203-481-0267
Mailing address:
  • Phone: 860-663-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number028902
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: