Basic Information
| Provider Information | |||||||||
| NPI: | 1780640508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOVANOVIC | ||||||||
| FirstName: | VESNA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9450 SW BARNES RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929560 | ||||||||
| FaxNumber: | 5032929510 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 NE MULTNOMAH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929560 | ||||||||
| FaxNumber: | 5032929510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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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 | MD23109 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 287016 | 05 | OR | MEDICAID |