Provider Demographics
NPI:1639183874
Name:TETRICK, DAVID L
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:TETRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-6180
Mailing Address - Fax:317-621-6177
Practice Address - Street 1:9669 E 146TH ST
Practice Address - Street 2:SUITE 310
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-5005
Practice Address - Country:US
Practice Address - Phone:317-621-6170
Practice Address - Fax:317-621-6177
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035208A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000659797OtherANTHEM
IN100335770Medicaid
IN000000659374OtherANTHEM
INM400018904Medicare PIN
IN000000659797OtherANTHEM
IN100335770Medicaid
IN214580EMedicare PIN
INB29455Medicare UPIN