Provider Demographics
NPI:1164476206
Name:DIMITRIJEVIC, RODOLJUB (MD)
Entity Type:Individual
Prefix:DR
First Name:RODOLJUB
Middle Name:
Last Name:DIMITRIJEVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43421 GARFIELD RD
Mailing Address - Street 2:STE 1
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1133
Mailing Address - Country:US
Mailing Address - Phone:586-286-6072
Mailing Address - Fax:586-286-0900
Practice Address - Street 1:43421 GARFIELD RD
Practice Address - Street 2:STE 1
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1133
Practice Address - Country:US
Practice Address - Phone:586-286-6072
Practice Address - Fax:586-286-0900
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD034830207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2115483Medicaid
MI1164476206Medicaid
MIP00438007OtherRR MEDICARE
MI0N31900012Medicare PIN
MI1164476206Medicaid
MIB43887Medicare UPIN
MI0505195Medicare ID - Type Unspecified