MEDICARE: MR. RADOVAN ANZULOVIC PA

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	363A00000X	Physician Assistant	PA.0005629	CO
2	363A00000X	Physician Assistant	PA56599	CA

General Provider Information

NPI Number	:	1518427129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RADOVAN ANZULOVIC PA

Provider Business Mailing Address
First Line	:	179 N ELM ST
Second Line	:
City	:	FRUITA
State	:	CO
Zip	:	81521-2208
Country	:	US
Telephone Number	:	303-667-3254
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 W HOBSONWAY
Second Line	:
City	:	BLYTHE
State	:	CA
Zip	:	92225-1651
Country	:	US
Telephone Number	:	760-660-4790
Fax Number	:	866-554-1794

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/05/2026

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Directions to “ MR. RADOVAN ANZULOVIC PA” Practice Location

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