Provider Demographics
NPI:1023062866
Name:KNEZEVIC, DUSAN (MD)
Entity type:Individual
Prefix:
First Name:DUSAN
Middle Name:
Last Name:KNEZEVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HIGHLAND AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1527
Mailing Address - Country:US
Mailing Address - Phone:973-748-9555
Mailing Address - Fax:973-748-2003
Practice Address - Street 1:123 HIGHLAND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1527
Practice Address - Country:US
Practice Address - Phone:973-748-9555
Practice Address - Fax:973-748-2003
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07449000207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9127402Medicaid
069772BFZMedicare ID - Type Unspecified
NJ9127402Medicaid