Provider Demographics
NPI:1336178540
Name:BANOVAC, KRESIMIR (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KRESIMIR
Middle Name:
Last Name:BANOVAC
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 1:1611 NW 12TH AVE
Mailing Address - Street 2:BOX 016960 M851
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-8740
Mailing Address - Fax:305-243-4650
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-8740
Practice Address - Fax:305-243-4650
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0665584-00Medicaid
D27945Medicare UPIN
FL0665584-00Medicaid