Provider Demographics
NPI:1205932332
Name:DRAGISIC, PETER B (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:DRAGISIC
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 1:4201 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2615
Mailing Address - Country:US
Mailing Address - Phone:708-636-1466
Mailing Address - Fax:708-636-0264
Practice Address - Street 1:4201 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2615
Practice Address - Country:US
Practice Address - Phone:708-636-1466
Practice Address - Fax:708-636-0264
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636324OtherBCBS
IL016092116Medicaid
ILG18635Medicare UPIN
IL01636324OtherBCBS