Healthcare Provider Details

I. General information

NPI: 1609839257
Provider Name (Legal Business Name): MLADEN DJURASOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E GRAY ST SUITE 900
LOUISVILLE KY
40202-3900
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-584-7525
  • Fax: 502-584-6851
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number36490
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: