Provider Demographics
NPI:1649315243
Name:TETRO, IDA (MD)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:TETRO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6960 108TH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4323
Mailing Address - Country:US
Mailing Address - Phone:718-263-0200
Mailing Address - Fax:718-263-0205
Practice Address - Street 1:6960 108TH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4323
Practice Address - Country:US
Practice Address - Phone:718-263-0200
Practice Address - Fax:718-263-0205
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220405207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04627Medicare PIN