Provider Demographics
NPI:1437460193
Name:ODARICH, TETYANA O (MD)
Entity Type:Individual
Prefix:
First Name:TETYANA
Middle Name:O
Last Name:ODARICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TETYANA
Other - Middle Name:O
Other - Last Name:SMOLYANSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9300 SE 91ST AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3762
Mailing Address - Country:US
Mailing Address - Phone:503-387-7111
Mailing Address - Fax:503-576-7706
Practice Address - Street 1:9300 SE 91ST AVE STE 201
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3762
Practice Address - Country:US
Practice Address - Phone:503-387-7111
Practice Address - Fax:503-576-7706
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD182578207Q00000X
WAML60163177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020971Medicaid
G8921382Medicare PIN