Individual
DEJAN MAKSIMOVIC
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
5114 N GLEN PARK PLACE RD, PEORIA, IL 61614-4686
(309) 655-2431
(309) 683-2412
Mailing address
5114 N GLEN PARK PLACE RD, PEORIA, IL 61614-4686
(309) 655-2431
(309) 683-2412
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036124188
IL
207Q00000X
Family Medicine Physician
56981
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
809840
MEDICARE GROUP PTAN
IL
01
—
809840038
MEDICARE INDIVIDUAL PTAN
IL
Enumeration date
06/29/2007
Last updated
10/06/2014
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