Provider Demographics
NPI:1376733782
Name:VIRGINIA PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:VIRGINIA PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIJANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUCIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-717-4090
Mailing Address - Street 1:5275 LEE HIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207
Mailing Address - Country:US
Mailing Address - Phone:703-717-4090
Mailing Address - Fax:703-717-4091
Practice Address - Street 1:5275 LEE HIGHWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207
Practice Address - Country:US
Practice Address - Phone:703-717-4090
Practice Address - Fax:703-717-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
VA01010577722080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74088Medicare UPIN
VAG02252Medicare PIN