Provider Demographics
NPI:1003967142
Name:TUBERVILLE, AUDREY W (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:W
Last Name:TUBERVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 N FLECHA DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6726
Mailing Address - Country:US
Mailing Address - Phone:520-529-2361
Mailing Address - Fax:520-577-0934
Practice Address - Street 1:3601 S 6TH ST
Practice Address - Street 2:EYE CLINIC
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35431174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3187169Medicaid
TNB04266Medicare UPIN
TN3187169Medicaid