Provider Demographics
NPI:1326002411
Name:TAETLE, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:TAETLE
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 1:1760 E RIVER RD
Mailing Address - Street 2:350
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5999
Mailing Address - Country:US
Mailing Address - Phone:520-519-7775
Mailing Address - Fax:520-519-7910
Practice Address - Street 1:603 N WILMOT RD
Practice Address - Street 2:STE 151
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2701
Practice Address - Country:US
Practice Address - Phone:520-886-0206
Practice Address - Fax:520-886-0829
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20032207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ011552Medicaid
AZ86-0938204OtherTIN
AZ011552Medicaid
AZZ25309Medicare PIN