Provider Demographics
NPI:1396086286
Name:VANDJELOVIC, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:VANDJELOVIC
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 1:875S BRYS DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1209
Mailing Address - Country:US
Mailing Address - Phone:804-929-2964
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST # 9C
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-5147
Practice Address - Fax:313-966-0880
Is Sole Proprietor?:No
Enumeration Date:2013-03-03
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2979402080P0214X
390200000X
MI5101020558207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program