Provider Demographics
NPI:1063504579
Name:VIDOVIC, MARINA (MD)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:VIDOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:TKALCEVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1945 W WILSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-769-4600
Mailing Address - Fax:773-769-0024
Practice Address - Street 1:1945 W WILSON AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-769-4600
Practice Address - Fax:773-769-0024
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF66747Medicare UPIN