Healthcare Provider Details

I. General information

NPI: 1760418560
Provider Name (Legal Business Name): TATJANA DERETIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 112TH AVE SE STE. 100
BELLEVUE WA
98004-6901
US

IV. Provider business mailing address

1400 112TH AVE SE STE. 100
BELLEVUE WA
98004-6901
US

V. Phone/Fax

Practice location:
  • Phone: 425-221-7427
  • Fax: 425-502-6092
Mailing address:
  • Phone: 425-221-7427
  • Fax: 425-502-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00043497
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00043497
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: