Provider Demographics
NPI:1740213503
Name:DJURISIC, TAMARA (MD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:DJURISIC
Suffix:
Gender:F
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:480-455-3000
Mailing Address - Fax:866-819-6115
Practice Address - Street 1:9590 E IRONWOOD SQUARE DR
Practice Address - Street 2:STE 125
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4581
Practice Address - Country:US
Practice Address - Phone:480-455-3000
Practice Address - Fax:866-819-6115
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108660207Q00000X
AZ45153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108660Medicaid
AZ631482Medicaid
AZZ172352Medicare PIN
I05823Medicare UPIN
IL036108660Medicaid