Healthcare Provider Details

I. General information

NPI: 1992179865
Provider Name (Legal Business Name): MIRJANA RUDIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRJANA RADIVOJEVIC

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 BELLEVUE WAY NE
BELLEVUE WA
98004-5720
US

IV. Provider business mailing address

PO BOX 350
MAPLE VALLEY WA
98038-0350
US

V. Phone/Fax

Practice location:
  • Phone: 425-455-5596
  • Fax: 425-451-3248
Mailing address:
  • Phone: 425-358-0956
  • Fax: 877-481-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA 60437694
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: