Provider Demographics
NPI:1497727002
Name:DACIC, SANJA (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:SANJA
Middle Name:
Last Name:DACIC
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 CEDAR STREET PO BOX 208023
Mailing Address - Street 2:YSM BRADY MEMORIAL LABORATORY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520
Mailing Address - Country:US
Mailing Address - Phone:203-785-3624
Mailing Address - Fax:203-785-7037
Practice Address - Street 1:310 CEDAR STREET
Practice Address - Street 2:YSM BRADY MEMORIAL LABORATORY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520
Practice Address - Country:US
Practice Address - Phone:203-785-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT70365207ZP0101X
PAMD072759L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001891077Medicaid
PAH56043Medicare UPIN