Provider Demographics
NPI:1598008062
Name:TETRAULT, STEPHEN WBS (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WBS
Last Name:TETRAULT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:17675 WELCH PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3551
Practice Address - Country:US
Practice Address - Phone:402-354-7600
Practice Address - Fax:402-354-7605
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE1223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731749Medicaid
IA1598008062Medicaid
NE47068731741Medicaid
NE10025464000Medicaid
NE47068731734Medicaid
NE10026480100Medicaid
NE099099312Medicare PIN