Provider Demographics
NPI:1912936824
Name:STEFANOVIC, MILICA (MD)
Entity Type:Individual
Prefix:DR
First Name:MILICA
Middle Name:
Last Name:STEFANOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4448 AMBROSE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2115
Mailing Address - Country:US
Mailing Address - Phone:323-644-1998
Mailing Address - Fax:323-644-2600
Practice Address - Street 1:4448 AMBROSE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2115
Practice Address - Country:US
Practice Address - Phone:323-644-1998
Practice Address - Fax:323-644-2600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2162002084P0800X
NY216200NY2084P0800X
CAA914132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI12130OtherRI LICENSE NUMBER
RI2936824Medicaid
NY02080642Medicaid
RI12130OtherRI LICENSE NUMBER
RI2936824Medicaid
RI007059020Medicare PIN