Healthcare Provider Details

I. General information

NPI: 1174558365
Provider Name (Legal Business Name): JOSEPH BERTRAND D. AUDETTE II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BERTRAND D. AUDETTE II DO

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S DELAWARE DRIVE SUITES 1&2
APACHE JUNCTION AZ
85120-6512
US

IV. Provider business mailing address

105 S DELAWARE DRIVE SUITES 1&2
APACHE JUNCTION AZ
85120-6512
US

V. Phone/Fax

Practice location:
  • Phone: 480-646-1001
  • Fax: 480-646-1002
Mailing address:
  • Phone: 480-646-1001
  • Fax: 480-646-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1738
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: