Provider Demographics
NPI:1376539668
Name:DEMIDOVICH, TATYANA R (MD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:R
Last Name:DEMIDOVICH
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 1:3635 VISTA FDT3
Mailing Address - Street 2:ST LOUIS UNIVERSITY
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE FDT3
Practice Address - Street 2:ST LOUIS UNIVERSITY
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-577-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059495A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200253830Medicaid
IN214320RMedicare ID - Type Unspecified
IN200253830Medicaid