Provider Demographics
NPI:1689606782
Name:TUBOKU-METZGER, ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:TUBOKU-METZGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 BRANDYWISE RD
Mailing Address - Street 2:#3A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:404-256-2593
Mailing Address - Fax:678-547-1494
Practice Address - Street 1:202 VILLAGE CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:678-547-1494
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0272542080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00303707CMedicaid
GA00303707CMedicaid
D31059Medicare UPIN