Basic Information
| Provider Information | |||||||||
| NPI: | 1669852711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JULOVICH | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | DEBORAH ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
| FaxNumber: | 2604585831 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 CAREW ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604256200 | ||||||||
| FaxNumber: | 2604256205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01078959A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11018182 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.