Provider Demographics
NPI:1780857839
Name:RUSSELL, MILICA KOVIJANIC (AUD AUDIOLOGY)
Entity type:Individual
Prefix:
First Name:MILICA
Middle Name:KOVIJANIC
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:AUD AUDIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 GEARY BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3118
Mailing Address - Country:US
Mailing Address - Phone:415-833-8222
Mailing Address - Fax:
Practice Address - Street 1:4141 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3109
Practice Address - Country:US
Practice Address - Phone:415-833-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7310237600000X
CAAU2498231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI569030Medicaid