Provider Demographics
NPI:1952350621
Name:VIDOVICH, MLADEN (MD)
Entity type:Individual
Prefix:DR
First Name:MLADEN
Middle Name:
Last Name:VIDOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 W ADAMS ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-5212
Mailing Address - Country:US
Mailing Address - Phone:312-704-2885
Mailing Address - Fax:312-704-2737
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:DEPT 3462
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-704-2885
Practice Address - Fax:312-704-2737
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094243207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G84891Medicare UPIN