Provider Demographics
NPI:1992179865
Name:RUDIC, MIRJANA
Entity Type:Individual
Prefix:
First Name:MIRJANA
Middle Name:
Last Name:RUDIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRJANA
Other - Middle Name:
Other - Last Name:RADIVOJEVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-0350
Mailing Address - Country:US
Mailing Address - Phone:425-358-0956
Mailing Address - Fax:877-481-6931
Practice Address - Street 1:208 BELLEVUE WAY NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5720
Practice Address - Country:US
Practice Address - Phone:425-455-5596
Practice Address - Fax:425-451-3248
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA 60437694237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2049826Medicaid