Provider Demographics
NPI:1891992269
Name:MAKSIMOVIC, DEJAN (DO)
Entity Type:Individual
Prefix:
First Name:DEJAN
Middle Name:
Last Name:MAKSIMOVIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5114 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4686
Mailing Address - Country:US
Mailing Address - Phone:309-655-2431
Mailing Address - Fax:309-683-2412
Practice Address - Street 1:5114 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-655-2431
Practice Address - Fax:309-683-2412
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56981207Q00000X
IL036124188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IL809840038OtherMEDICARE INDIVIDUAL PTAN