Provider Demographics
NPI:1023067147
Name:BRKIC-VUKOTIC, OGNJENKA GOGA (MD)
Entity type:Individual
Prefix:DR
First Name:OGNJENKA
Middle Name:GOGA
Last Name:BRKIC-VUKOTIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GOGA
Other - Middle Name:
Other - Last Name:BRKIC- VUKOTIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11050 CRABAPPLE RD
Mailing Address - Street 2:SUITE 104 B
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2489
Mailing Address - Country:US
Mailing Address - Phone:770-645-0017
Mailing Address - Fax:770-645-0224
Practice Address - Street 1:11050 CRABAPPLE RD
Practice Address - Street 2:SUITE 104 B
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2489
Practice Address - Country:US
Practice Address - Phone:770-645-0017
Practice Address - Fax:770-645-0224
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047576207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH06378Medicare UPIN