Provider Demographics
NPI:1033135686
Name:LJUBANOVIC LAZAREVIC, MARIJANA
Entity Type:Individual
Prefix:
First Name:MARIJANA
Middle Name:
Last Name:LJUBANOVIC LAZAREVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:735 JELKE ANESTHESIA DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-6504
Mailing Address - Fax:312-942-5773
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:735 JELKE ANESTHESIA DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6504
Practice Address - Fax:312-942-5773
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093273207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21629Medicare PIN