Provider Demographics
NPI:1407905037
Name:DORDEVICH, DEJAN MILORAD (MD)
Entity Type:Individual
Prefix:DR
First Name:DEJAN
Middle Name:MILORAD
Last Name:DORDEVICH
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 1:545 NE 47TH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2287
Mailing Address - Country:US
Mailing Address - Phone:503-231-7622
Mailing Address - Fax:
Practice Address - Street 1:545 NE 47TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2287
Practice Address - Country:US
Practice Address - Phone:503-231-7622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10741207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR263046Medicaid
OR263046Medicaid
ORB18216Medicare UPIN