Provider Demographics
NPI:1699856278
Name:AUDIE M TEAGUE O D P A
Entity Type:Organization
Organization Name:AUDIE M TEAGUE O D P A
Other - Org Name:TEAGUE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-887-3596
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-0189
Mailing Address - Country:US
Mailing Address - Phone:870-887-3596
Mailing Address - Fax:870-887-3945
Practice Address - Street 1:204 E 2ND SREET S
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857
Practice Address - Country:US
Practice Address - Phone:870-887-3596
Practice Address - Fax:870-887-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR410011556OtherRAILROAD MEDICARE
AR112122722Medicaid
AR0189210001Medicare NSC
AR112122722Medicaid