Provider Demographics
NPI:1255333282
Name:ZIVKOVIC, DEJAN (MS)
Entity Type:Individual
Prefix:
First Name:DEJAN
Middle Name:
Last Name:ZIVKOVIC
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:850 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1493
Practice Address - Country:US
Practice Address - Phone:440-808-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67000093367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375522Medicaid