MEDICARE: MARIJA DRAGICA MUTABDZIC 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	2084P0804X	Child & Adolescent Psychiatry Physician	260428	NY

General Provider Information

NPI Number	:	1891803227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIJA DRAGICA MUTABDZIC MD

Provider Business Mailing Address
First Line	:	4 COUNTRY LN
Second Line	:
City	:	OSWEGO
State	:	NY
Zip	:	13126-4100
Country	:	US
Telephone Number	:	315-216-6995
Fax Number	:

Provider Business Practice Location Address
First Line	:	98 N 2ND ST
Second Line	:
City	:	FULTON
State	:	NY
Zip	:	13069-1254
Country	:	US
Telephone Number	:	315-326-3555
Fax Number	:

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	07/01/2011

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