Provider Demographics
NPI:1811121502
Name:MICIC, VESNA (MD)
Entity type:Individual
Prefix:
First Name:VESNA
Middle Name:
Last Name:MICIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W END AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1320
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:888-468-6603
Practice Address - Street 1:808 COLUMBUS AVE APT 21D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5169
Practice Address - Country:US
Practice Address - Phone:832-370-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1042012084N0400X
WI627802084N0402X
NY2734872084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDJ571YMedicare PIN