Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | MD20050640 | NM |
NPI | 1003840208 |
---|---|
Provider Name | Ivana Radovanovic |
First Address | Albuquerque, NM 87131-0001 |
Second Address | Albuquerque, NM 87131-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 19/11/2008 |