Provider Demographics
NPI:1750452801
Name:MODRIC JEDNACAK, KSENIJA (MD)
Entity Type:Individual
Prefix:DR
First Name:KSENIJA
Middle Name:
Last Name:MODRIC JEDNACAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KSENIJA
Other - Middle Name:
Other - Last Name:MODRIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6726 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3254
Mailing Address - Country:US
Mailing Address - Phone:414-774-4074
Mailing Address - Fax:414-774-0471
Practice Address - Street 1:6726 CEDAR ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3254
Practice Address - Country:US
Practice Address - Phone:414-774-4074
Practice Address - Fax:414-774-0471
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47908-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology