Provider Demographics
NPI:1568530699
Name:RADULOVACKI, BRANKO (MD)
Entity Type:Individual
Prefix:
First Name:BRANKO
Middle Name:
Last Name:RADULOVACKI
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 1:4015 SOUTH COBB DRIVE
Mailing Address - Street 2:STE 110B
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-434-5833
Mailing Address - Fax:770-437-0680
Practice Address - Street 1:4015 SOUTH COBB DRIVE
Practice Address - Street 2:STE 110B
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-434-5833
Practice Address - Fax:770-437-0680
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0488122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDHFBMedicare ID - Type Unspecified
H15923Medicare UPIN