Healthcare Provider Details

I. General information

NPI: 1699188201
Provider Name (Legal Business Name): BRANKO LAZAREVIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N SENATE AVE
INDIANAPOLIS IN
46202-2213
US

IV. Provider business mailing address

3345 NEW BRIGHTON GARDENS SE
CALGARY ALBERTA
T2A 0A2
CA

V. Phone/Fax

Practice location:
  • Phone: 917-216-8999
  • Fax:
Mailing address:
  • Phone: 917-216-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11017808A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: