Provider Demographics
NPI:1124074752
Name:ANTIC, GORAN DJORDJE (MD)
Entity type:Individual
Prefix:
First Name:GORAN
Middle Name:DJORDJE
Last Name:ANTIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1265 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4541
Practice Address - Country:US
Practice Address - Phone:931-363-7531
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00372629OtherRAILROAD MEDICARE
TN3859664Medicaid
TN4072313OtherBCBSTN
TNP00372629OtherRAILROAD MEDICARE
TN3859664Medicaid