Provider Demographics
NPI:1023351921
Name:RAJACIC, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:RAJACIC
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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:267-428-6575
Mailing Address - Fax:
Practice Address - Street 1:6431 SACKETT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-3118
Practice Address - Country:US
Practice Address - Phone:267-448-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17113207R00000X
390200000X
PAMD466541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program