MEDICARE: LIDIJA PETROVIC MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0101X	Anatomic Pathology Physician	226218	NY
2	207ZP0101X	Anatomic Pathology Physician	A52273	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	W7801B	OTHER	CA	GROUP MEDICARE #
6	HW7801B	OTHER	CA	GROUP MEDICARE #
7	HW7801A	OTHER	CA	GROUP MEDICARE #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ54738Z	OTHER	CA	GROUP BLUE SHIELD #
2	ZZZ94714Z	OTHER	CA	GROUP BLUE SHIELD #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	ZZZ31029Z	OTHER	CA	GROUP BLUE SHIELD #
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457326266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIDIJA PETROVIC MD

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-442-2582
Fax Number	:	323-442-2588

Provider Business Practice Location Address
First Line	:	1510 SAN PABLO ST FL 6
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5320
Country	:	US
Telephone Number	:	323-442-4815
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	12/11/2013

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Directions to “ LIDIJA PETROVIC MD” Practice Location

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