Provider Demographics
NPI:1013545862
Name:RADISIC, ANNA (MD)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:RADISIC
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 1:17 DAVIS BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 ESSEX ST STE 102
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2709
Practice Address - Country:US
Practice Address - Phone:551-996-8111
Practice Address - Fax:551-996-8445
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME160304207R00000X
NJ25MA12521300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118138600Medicaid
FLS4OQ7OtherBLUE CROSS BLUE SHIELD