Provider Demographics
NPI:1063780740
Name:KRISTOVICH, NEDJELKO
Entity type:Individual
Prefix:
First Name:NEDJELKO
Middle Name:
Last Name:KRISTOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21555 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-6539
Mailing Address - Country:US
Mailing Address - Phone:408-569-9442
Mailing Address - Fax:408-257-3471
Practice Address - Street 1:21555 PROSPECT RD
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-6539
Practice Address - Country:US
Practice Address - Phone:408-569-9442
Practice Address - Fax:408-257-3471
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN5020399172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver