Provider Demographics
NPI:1760418560
Name:DERETIC, TATJANA (MD)
Entity Type:Individual
Prefix:
First Name:TATJANA
Middle Name:
Last Name:DERETIC
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 1:1400 112TH AVE SE
Mailing Address - Street 2:STE. 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6901
Mailing Address - Country:US
Mailing Address - Phone:425-221-7427
Mailing Address - Fax:425-502-6092
Practice Address - Street 1:1400 112TH AVE SE
Practice Address - Street 2:STE. 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6901
Practice Address - Country:US
Practice Address - Phone:425-221-7427
Practice Address - Fax:425-502-6092
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000434972084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8405250Medicaid