Healthcare Provider Details

I. General information

NPI: 1417384694
Provider Name (Legal Business Name): DJORDJE ATANACKOVIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

203 TUNBRIDGE RD
BALTIMORE MD
21212-3423
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-1946
  • Fax:
Mailing address:
  • Phone: 385-242-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number8702756-1252
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number8702756-1252
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: