Provider Demographics
NPI:1831775873
Name:IBRISIMOVIC, ADVIJA (MD)
Entity type:Individual
Prefix:
First Name:ADVIJA
Middle Name:
Last Name:IBRISIMOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADVIJA
Other - Middle Name:
Other - Last Name:LISIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:361 SHADOWBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2161 W SPRING ST STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3196
Practice Address - Country:US
Practice Address - Phone:770-267-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine