Provider Demographics
NPI:1245261015
Name:GARDILCIC, STJEPAN (MD)
Entity type:Individual
Prefix:DR
First Name:STJEPAN
Middle Name:
Last Name:GARDILCIC
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 1:675 BALLY ROW
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906
Mailing Address - Country:US
Mailing Address - Phone:419-756-4999
Mailing Address - Fax:419-756-4949
Practice Address - Street 1:675 BALLY ROW
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906
Practice Address - Country:US
Practice Address - Phone:419-756-4999
Practice Address - Fax:419-756-4949
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062560208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0849809Medicaid
OH000000198537OtherBLUE CROSS
OHGA0704712Medicare PIN
OH000000198537OtherBLUE CROSS