Healthcare Provider Details

I. General information

NPI: 1821199266
Provider Name (Legal Business Name): RADOVAN BUBANJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

608 W PHIL ELLENA ST APT 2A
PHILADELPHIA PA
19119-3525
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD030270E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: