Provider Demographics
NPI:1588283006
Name:EJUPOVIC, ADNAN (DPM)
Entity type:Individual
Prefix:
First Name:ADNAN
Middle Name:
Last Name:EJUPOVIC
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3571
Mailing Address - Country:US
Mailing Address - Phone:810-982-4240
Mailing Address - Fax:586-429-1501
Practice Address - Street 1:1217 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3571
Practice Address - Country:US
Practice Address - Phone:810-982-4240
Practice Address - Fax:586-429-1501
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.004096213ES0103X
OH390200000X
MI5901400528213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program