Healthcare Provider Details

I. General information

NPI: 1184774200
Provider Name (Legal Business Name): BRANKICA LAZIC-MAZLAGIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HOPPIN ST. CORO CENTER 3RD FLR
PROVIDENCE RI
02903-4141
US

IV. Provider business mailing address

PO BOX 3238
BOSTON MA
02241-3238
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8790
  • Fax: 401-793-8709
Mailing address:
  • Phone: 866-689-8862
  • Fax: 207-347-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number230847
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD13072
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: