Basic Information
| Provider Information | |||||||||
| NPI: | 1336660299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAGOVIC | ||||||||
| FirstName: | KRISTINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 LUCERNE TER FL 2 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078415297 | ||||||||
| FaxNumber: | 4074810182 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 W COPELAND DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078415281 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TRN25137 | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | TRN25137 | 05 | FL | MEDICAID |