Provider Demographics
NPI:1487632428
Name:MRDJENOVICH, DONALD E (DPM)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:MRDJENOVICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BEALE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1705
Mailing Address - Country:US
Mailing Address - Phone:814-946-1075
Mailing Address - Fax:814-946-4076
Practice Address - Street 1:2727 BEALE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1705
Practice Address - Country:US
Practice Address - Phone:814-946-1075
Practice Address - Fax:814-946-4076
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003403L213E00000X, 213ER0200X, 213ES0131X
PASC0034031213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0707106OtherAETNA HMO QPOS
PACC2226OtherRAILROAD MEDICARE GROUP
PA0016415200001Medicaid
PA21139415759OtherBEECH STREET
PA21139415759OtherINTERGROUP
PA480019774OtherRAILROAD MEDICARE INDIVID
PAMR680859OtherBLUE SHIELD IND
PAP11111021OtherMULTIPLAN
PA0016415200002Medicaid
PA5082453OtherPPNI
PA826758OtherBLUE SHIELD GROUP
251775206OtherTAX ID FOR GROUP
PA000000087405OtherUNISON
PA000680859OtherKEYSTONE HEALTH PLAN
PA1024439OtherGATEWAY INDIVIDUAL
PA206170OtherUPMC
PA740952OtherFOCUS
PA21139415759OtherBEECH STREET
PA5082453OtherPPNI
PA0016415200001Medicaid
PA1115690001Medicare NSC