Provider Demographics
NPI:1659774172
Name:SAMOUKOVIC, GORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDAN
Middle Name:
Last Name:SAMOUKOVIC
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 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:3RD FLOOR CARDIOVASCULAR CENTER RECP C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5864
Practice Address - Country:US
Practice Address - Phone:888-287-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105602208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care