Provider Demographics
NPI:1639115066
Name:TETREAULT, DOLORES YVONNE (MD)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:YVONNE
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GAMECOCK AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3398
Mailing Address - Country:US
Mailing Address - Phone:843-769-8215
Mailing Address - Fax:843-769-8216
Practice Address - Street 1:27 GAMECOCK AVE
Practice Address - Street 2:STE 201
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3398
Practice Address - Country:US
Practice Address - Phone:843-769-8215
Practice Address - Fax:843-769-8216
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171005207RG0300X
SC33970207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE15598Medicare UPIN