Provider Demographics
NPI:1134193774
Name:JUKIC, DRAZEN M (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:DRAZEN
Middle Name:M
Last Name:JUKIC
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:5400 SUTLIVE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4721
Practice Address - Country:US
Practice Address - Phone:912-232-7546
Practice Address - Fax:912-777-7798
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056878207ZD0900X, 207ZP0102X, 207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140616Medicaid
GA056878OtherGEORGIA LICENSE
FL003007800Medicaid
FL149H6OtherBLUE CROSS BLUE SHIELD
GA003140616Medicaid
GA202I227844Medicare PIN
FL149H6OtherBLUE CROSS BLUE SHIELD