Provider Demographics
NPI:1780640508
Name:JOVANOVIC, VESNA A (MD)
Entity Type:Individual
Prefix:
First Name:VESNA
Middle Name:A
Last Name:JOVANOVIC
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 1:9450 SW BARNES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6619
Mailing Address - Country:US
Mailing Address - Phone:503-292-9560
Mailing Address - Fax:503-292-9510
Practice Address - Street 1:700 NE MULTNOMAH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2131
Practice Address - Country:US
Practice Address - Phone:503-292-9560
Practice Address - Fax:503-292-9510
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287016Medicaid
OR110981Medicare ID - Type Unspecified
OR287016Medicaid