Provider Demographics
NPI:1427152891
Name:JEZDIC, SASA (ATC)
Entity type:Individual
Prefix:MR
First Name:SASA
Middle Name:
Last Name:JEZDIC
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21-26 NEWTOWN AV.
Mailing Address - Street 2:APT. 11
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102
Mailing Address - Country:US
Mailing Address - Phone:718-709-1557
Mailing Address - Fax:
Practice Address - Street 1:30 WALL ST
Practice Address - Street 2:4TH. FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-2201
Practice Address - Country:US
Practice Address - Phone:212-514-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001272-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer