Provider Demographics
NPI:1407895840
Name:MATAIC, DANIJELA (MD)
Entity Type:Individual
Prefix:
First Name:DANIJELA
Middle Name:
Last Name:MATAIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:374B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-842-9669
Mailing Address - Fax:314-842-1017
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:374B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-842-9669
Practice Address - Fax:314-842-1017
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003811207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH25546Medicare UPIN