Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 4301089472 | MI |
Y | 111NI0900X | Internist | 4301089472 | MI |
NPI | 1003055252 |
---|---|
Provider Name | Dr. Oliver Dimitrijevic |
First Address | Grosse Pointe Woods, MI 48236-2893 |
Second Address | Warren, MI 48088-6683 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/02/2009 |
Last Update Date | 05/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
700E012740 | BCBS GROUP NUMBER (01) | MI |