Provider Demographics
NPI:1174843064
Name:TETALMAN, BRUCE IRA
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:IRA
Last Name:TETALMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IRA
Other - Middle Name:BRUCE
Other - Last Name:TETALMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:716 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4545
Mailing Address - Country:US
Mailing Address - Phone:757-323-5516
Mailing Address - Fax:
Practice Address - Street 1:716 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4545
Practice Address - Country:US
Practice Address - Phone:757-323-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052269202C00000X, 2081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine