Provider Demographics
NPI:1508822602
Name:TRETTA, JOSEPH T (DO, PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:T
Last Name:TRETTA
Suffix:
Gender:M
Credentials:DO, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 BELFORT RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-2219
Practice Address - Fax:903-731-2246
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7643207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033590303Medicaid
TX8F1654Medicare PIN
B27072Medicare UPIN