Provider Demographics
NPI:1740200526
Name:ZELJKO ZIC M.D. INC.
Entity type:Organization
Organization Name:ZELJKO ZIC M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-548-0201
Mailing Address - Street 1:1294 W 6TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2993
Mailing Address - Country:US
Mailing Address - Phone:310-548-0101
Mailing Address - Fax:310-547-3340
Practice Address - Street 1:1294 W 2ND ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3208
Practice Address - Country:US
Practice Address - Phone:310-548-0201
Practice Address - Fax:310-547-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25474207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA83252Medicare UPIN