Provider Demographics
NPI:1891014619
Name:DAVID A. TETRAULT, OD, PC
Entity Type:Organization
Organization Name:DAVID A. TETRAULT, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF RETAIL
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-6215
Mailing Address - Street 1:2820 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-0801
Mailing Address - Country:US
Mailing Address - Phone:520-323-3937
Mailing Address - Fax:
Practice Address - Street 1:2820 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-0801
Practice Address - Country:US
Practice Address - Phone:520-323-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ046070Medicaid
AZ046070Medicaid