Provider Demographics
NPI:1578589636
Name:PREMUZIC, MLADEN (MD)
Entity Type:Individual
Prefix:
First Name:MLADEN
Middle Name:
Last Name:PREMUZIC
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 1:11510 GEORGIA AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1925
Mailing Address - Country:US
Mailing Address - Phone:301-946-5100
Mailing Address - Fax:301-929-0348
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:301-946-5100
Practice Address - Fax:301-929-0348
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD30003207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2495295OtherAETNA HMO
DC200138OtherKAISER
DC501345OtherNCPPO
DC5983731OtherAETNA NON HMO
VA5705011Medicaid
DC0094OtherCAREFIRST BCBS
VA441052OtherANTHEM BCBS
DC200138OtherKAISER
DC5983731OtherAETNA NON HMO