Provider Demographics
NPI:1528296753
Name:CORALIC, JASNA (MD)
Entity type:Individual
Prefix:
First Name:JASNA
Middle Name:
Last Name:CORALIC
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7233
Practice Address - Fax:414-298-7229
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2016-11-07
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Provider Licenses
StateLicense IDTaxonomies
WI62416-20208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528296753Medicaid
WI1528296753Medicaid
WI1528296753Medicaid