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NPI Code Detail

MEDICARE: TERESA J TIBBETTS M D LLC

MEDICARE: TERESA J TIBBETTS M D LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician27163AZ

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4DD0854OTHERRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
32Z2286OTHERHEALTH NET

General Provider Information

NPI Number : 1053594275
Entity Type Code : Organization
Provider Name (Legal Business Name) : TERESA J TIBBETTS M D LLC
Provider Business Mailing Address
First Line : PO BOX 2325
Second Line :
City : LAKE HAVASU CITY
State : AZ
Zip : 86405-2325
Country : US
Telephone Number : 928-680-4233
Fax Number : 928-680-6522
Provider Business Practice Location Address
First Line : 2082 MESQUITE AVE
Second Line : SUITE A106
City : LAKE HAVASU CITY
State : AZ
Zip : 86403-6710
Country : US
Telephone Number : 928-680-4233
Fax Number : 928-680-6522
Authorized Official
Title or Position : OWNER
Name : TERESA J TIBBETTS
Credential : MD
Telephone Number : 928-680-4233
Provider Enumeration Date : 12/11/2007
Last Update Date : 08/05/2008

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Directions to “TERESA J TIBBETTS M D LLC ” Practice Location

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