Provider Demographics
NPI:1730138603
Name:TETREAULT, WILLIAM R (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:TETREAULT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:3757 CARMAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-5418
Practice Address - Country:US
Practice Address - Phone:518-355-7063
Practice Address - Fax:518-357-0646
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2018-01-31
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Provider Licenses
StateLicense IDTaxonomies
NY170582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10002034OtherCDPHP ID
NY200199OtherSENIOR WHOLE HEALTH
NY691931OtherEMPIRE BC ID
NY5691317OtherAETNA ID
NY08194OtherMVP ID
NY47362OtherGHI/HMO ID
NY070216000069OtherFIDELIS
NY01133504Medicaid
NY000401102001OtherBSNENY ID
NY08194OtherMVP ID
NY10002034OtherCDPHP ID