Provider Demographics
NPI:1841239340
Name:LETELLIER, MARC ALAIN (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ALAIN
Last Name:LETELLIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4566 E INVERNESS AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4633
Mailing Address - Country:US
Mailing Address - Phone:480-730-1844
Mailing Address - Fax:480-730-1404
Practice Address - Street 1:4566 E INVERNESS AVE
Practice Address - Street 2:#205
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4633
Practice Address - Country:US
Practice Address - Phone:480-730-1844
Practice Address - Fax:480-730-1404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18410174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZB54552Medicare UPIN
AZWMBMRMedicare ID - Type UnspecifiedMEDICARE NUMBER