Basic Information
| Provider Information | |||||||||
| NPI: | 1679063622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DANIELA MICIC MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2021 SANTA MONICA BLVD STE 724E | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108299060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | MICIC | ||||||||
| AuthorizedOfficialFirstName: | DANIELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2138408284 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A122430 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.