Provider Demographics
NPI:1902869779
Name:PRVULOVIC, ALEKSANDAR
Entity Type:Individual
Prefix:
First Name:ALEKSANDAR
Middle Name:
Last Name:PRVULOVIC
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 1:385 PROSPECT AVE
Mailing Address - Street 2:N/A
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2570
Mailing Address - Country:US
Mailing Address - Phone:201-487-1390
Mailing Address - Fax:201-342-7962
Practice Address - Street 1:385 PROSPECT AVE
Practice Address - Street 2:N/A
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2570
Practice Address - Country:US
Practice Address - Phone:201-487-1390
Practice Address - Fax:201-342-7962
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07949700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI49025Medicare UPIN
NJ097971Medicare ID - Type UnspecifiedMEDICARE #