Provider Demographics
NPI:1457334914
Name:TETREAULT, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:TETREAULT
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3550
Practice Address - Street 1:2351 PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5333
Practice Address - Country:US
Practice Address - Phone:850-877-8166
Practice Address - Fax:850-877-0431
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65204207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256881100Medicaid
FL830005937OtherRR MEDICARE
FL46610ZMedicare PIN
FL46610YMedicare PIN
FL46610VMedicare PIN
FL256881100Medicaid