Provider Demographics
NPI:1346322880
Name:AULTMAN, TRICIA K (MD)
Entity Type:Individual
Prefix:DR
First Name:TRICIA
Middle Name:K
Last Name:AULTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TRICIA
Other - Middle Name:L
Other - Last Name:KUNOVICH-FRIEZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-809-5510
Practice Address - Fax:228-809-5519
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS17226207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSTA00125439Medicaid
MSTA00125439Medicaid
MSH57159Medicare UPIN
TA110001608Medicare ID - Type Unspecified