Basic Information
| Provider Information | |||||||||
| NPI: | 1811121502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICIC | ||||||||
| FirstName: | VESNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 W END AVE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
| FaxNumber: | 8884686603 | ||||||||
| Practice Location | |||||||||
| Address1: | 808 COLUMBUS AVE APT 21D | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100255169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323703789 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | ME104201 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0402X | 62780 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 273487 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.