Provider Demographics
NPI:1366458127
Name:TETRAULT, GREGORY ALAN (M D)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:TETRAULT
Suffix:
Gender:M
Credentials:M D
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Other - Credentials:
Mailing Address - Street 1:1603 PECAN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9096
Mailing Address - Country:US
Mailing Address - Phone:901-861-3716
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:MEDICAL CENTER 614/113
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:901-577-7284
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN37956207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine