Healthcare Provider Details

I. General information

NPI: 1538723762
Provider Name (Legal Business Name): MARIJA PETROVIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 5TH AVE
NEW YORK NY
10029-6503
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-427-1540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number336473
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: