Provider Demographics
NPI:1003841321
Name:TETRAULT, JEANETTE M (MD)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:M
Last Name:TETRAULT
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 1:1 LONG WHARF DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01033OtherMEDICARE PTAN
CT008023170Medicaid
CT004041000Medicaid
CT004082286Medicaid
CT008001325Medicaid
CT008039745Medicaid
CT500000315Medicaid
CT001423136Medicaid
CT004217099Medicaid
CT004082260Medicaid
CT008022622Medicaid
CT008022626Medicaid
CT008024427Medicaid
CT008042339Medicaid
CTD400081097OtherMEDICARE GROUP MEMBER PIN/PTAN
CT004041000Medicaid