Healthcare Provider Details

I. General information

NPI: 1720223654
Provider Name (Legal Business Name): DRAGANA CUPIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

IV. Provider business mailing address

925 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036046112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: