Provider Demographics
NPI:1114038692
Name:TETRAULT, DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:TETRAULT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N ALVERNON WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1958
Mailing Address - Country:US
Mailing Address - Phone:520-327-6215
Mailing Address - Fax:520-327-6546
Practice Address - Street 1:2894 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2876
Practice Address - Country:US
Practice Address - Phone:520-323-3937
Practice Address - Fax:520-323-3938
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ046070Medicaid
AZU13503Medicare UPIN
AZ046070Medicaid