Provider Demographics
NPI:1174527436
Name:STIPIC-PETROVIC, DESANKA (MD)
Entity type:Individual
Prefix:DR
First Name:DESANKA
Middle Name:
Last Name:STIPIC-PETROVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESANKA
Other - Middle Name:
Other - Last Name:STIPIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19900 E. 10 MILE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-4412
Mailing Address - Country:US
Mailing Address - Phone:586-776-3366
Mailing Address - Fax:586-774-1808
Practice Address - Street 1:19900 E. 10 MILE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-4412
Practice Address - Country:US
Practice Address - Phone:586-776-3366
Practice Address - Fax:586-774-1808
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0605792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3018457 TYPE10Medicaid
MI0E04717-0261/003Medicare ID - Type Unspecified