Provider Demographics
NPI:1396384707
Name:POPOVICH, JOVAN VASILIJA
Entity Type:Individual
Prefix:
First Name:JOVAN
Middle Name:VASILIJA
Last Name:POPOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31328 LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-2018
Mailing Address - Country:US
Mailing Address - Phone:586-863-3081
Mailing Address - Fax:
Practice Address - Street 1:300 JUBILEE DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4068
Practice Address - Country:US
Practice Address - Phone:877-341-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant