Provider Demographics
NPI:1841796778
Name:DEJANOVIC, ILJA
Entity Type:Individual
Prefix:
First Name:ILJA
Middle Name:
Last Name:DEJANOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-4001
Mailing Address - Country:US
Mailing Address - Phone:201-655-5440
Mailing Address - Fax:
Practice Address - Street 1:2449 1ST ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4001
Practice Address - Country:US
Practice Address - Phone:201-655-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program