Provider Demographics
NPI:1164489225
Name:TETIRICK, CARL E (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:E
Last Name:TETIRICK
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 1:243 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743
Mailing Address - Country:US
Mailing Address - Phone:603-542-6777
Mailing Address - Fax:603-542-6731
Practice Address - Street 1:251 ELM STREET
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-542-6777
Practice Address - Fax:603-542-6731
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6455208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH00000192Medicaid
VT1000697Medicaid
VT1000697Medicaid