Provider Demographics
NPI:1194770990
Name:JEZIC, GORAN A (MD)
Entity type:Individual
Prefix:
First Name:GORAN
Middle Name:A
Last Name:JEZIC
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 1:1200 BINZ ST
Mailing Address - Street 2:SUITE 970
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6900
Mailing Address - Country:US
Mailing Address - Phone:713-400-1005
Mailing Address - Fax:713-400-1006
Practice Address - Street 1:1200 BINZ ST
Practice Address - Street 2:SUITE 970
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6900
Practice Address - Country:US
Practice Address - Phone:713-400-1005
Practice Address - Fax:713-400-1006
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4237208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
610478Medicare PIN
TXG34599Medicare UPIN