Provider Demographics
NPI:1053930941
Name:KAJTEZOVIC, SIDIKA
Entity type:Individual
Prefix:
First Name:SIDIKA
Middle Name:
Last Name:KAJTEZOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOSTON MEDICAL CTR PL STE 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2999
Mailing Address - Country:US
Mailing Address - Phone:617-414-5193
Mailing Address - Fax:
Practice Address - Street 1:89 BEAUMONT AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-1742
Practice Address - Country:US
Practice Address - Phone:802-656-2154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-11
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT3969239Medicaid