Provider Demographics
NPI:1871555177
Name:PREDRAG M GAGIC, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PREDRAG M GAGIC, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREDRAG
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAGIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-253-8655
Mailing Address - Street 1:313 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2841
Mailing Address - Country:US
Mailing Address - Phone:318-253-8655
Mailing Address - Fax:318-253-9737
Practice Address - Street 1:313 CENTER ST
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2841
Practice Address - Country:US
Practice Address - Phone:318-253-8655
Practice Address - Fax:318-253-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05101R208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4354175020OtherBLUE CROSS BLUE SHIELD
LA19D0464907OtherCLIA
LA1304841Medicaid
LA4354175020OtherBLUE CROSS BLUE SHIELD
LA19D0464907OtherCLIA