Provider Demographics
NPI:1174558365
Name:AUDETTE, JOSEPH BERTRAND D II (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BERTRAND D
Last Name:AUDETTE
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:BERTRAND
Other - Middle Name:D
Other - Last Name:AUDETTE
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:105 S DELAWARE DRIVE
Mailing Address - Street 2:SUITES 1&2
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-6512
Mailing Address - Country:US
Mailing Address - Phone:480-646-1001
Mailing Address - Fax:480-646-1002
Practice Address - Street 1:105 S DELAWARE DRIVE
Practice Address - Street 2:SUITES 1&2
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-6512
Practice Address - Country:US
Practice Address - Phone:480-646-1001
Practice Address - Fax:480-646-1002
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ976001Medicaid
MEH62023Medicare UPIN
AZZ172802Medicare PIN
AZ976001Medicaid