Provider Demographics
NPI:1659385516
Name:VUKASIN, PETAR (MD)
Entity Type:Individual
Prefix:
First Name:PETAR
Middle Name:
Last Name:VUKASIN
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 1:222 W EULALIA ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2849
Mailing Address - Country:US
Mailing Address - Phone:818-244-8161
Mailing Address - Fax:818-244-8161
Practice Address - Street 1:222 W EULALIA ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2849
Practice Address - Country:US
Practice Address - Phone:818-244-8161
Practice Address - Fax:818-244-8161
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74237208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34562Medicare UPIN
CABS560ZMedicare PIN