Healthcare Provider Details

I. General information

NPI: 1427152891
Provider Name (Legal Business Name): SASA JEZDIC ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WALL ST 4TH. FLOOR
NEW YORK NY
10005-2201
US

IV. Provider business mailing address

21-26 NEWTOWN AV. APT. 11
ASTORIA NY
11102
US

V. Phone/Fax

Practice location:
  • Phone: 212-514-6499
  • Fax:
Mailing address:
  • Phone: 718-709-1557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001272-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: