Provider Demographics
NPI:1811162704
Name:MAZE, JELICA (MD)
Entity type:Individual
Prefix:DR
First Name:JELICA
Middle Name:
Last Name:MAZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JELICA
Other - Middle Name:
Other - Last Name:JANICIJEVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:12750 ST FRANCIS DR STE 320
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-0264
Practice Address - Country:US
Practice Address - Phone:219-662-0077
Practice Address - Fax:219-662-9496
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077479A207R00000X, 207RC0000X
PAMD445339207RC0000X
FLME112860207RC0000X
IL036132452207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036132452Medicaid
IL1124399605OtherBCBS GROUP