Provider Demographics
NPI:1427077569
Name:TRETIAK, SEAN HENRY (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:HENRY
Last Name:TRETIAK
Suffix:
Gender:M
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:770-701-6651
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-325-9110
Practice Address - Fax:310-784-8762
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65535207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A655350Medicaid
CA00A655350OtherBLUE SHIELD
CA00A655350Medicaid
CA00A655350OtherBLUE SHIELD