Provider Demographics
NPI:1508883208
Name:STEVANOVIC, RADOMIR D (MD)
Entity Type:Individual
Prefix:
First Name:RADOMIR
Middle Name:D
Last Name:STEVANOVIC
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 1:2343 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1092
Mailing Address - Country:US
Mailing Address - Phone:607-266-9100
Mailing Address - Fax:607-266-9200
Practice Address - Street 1:2343 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1092
Practice Address - Country:US
Practice Address - Phone:607-266-9100
Practice Address - Fax:607-266-9200
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176403207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01122458Medicaid
NY13F991Medicare PIN