Healthcare Provider Details

I. General information

NPI: 1598285165
Provider Name (Legal Business Name): STEFANI STEVANIJA TICA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR STE 4210
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

705 RILEY HOSPITAL DR STE 4200
INDIANAPOLIS IN
46202-5109
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-3774
  • Fax: 317-968-1055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020013471
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2020013471
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2020013471
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2020013471
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number01094083A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: