Provider Demographics
NPI:1750486445
Name:TIBBETTS, TERESA J (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:J
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2325
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-2325
Mailing Address - Country:US
Mailing Address - Phone:928-680-4233
Mailing Address - Fax:928-680-6522
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6710
Practice Address - Country:US
Practice Address - Phone:928-680-4233
Practice Address - Fax:928-680-6522
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ27163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102474OtherMEDICARE INDIVIDUAL PTAN
AZ474429Medicaid
AZDD0854OtherRAILROAD MEDICARE GROUP #
AZ2Z2286OtherHEALTH NET PROVIDER #
AZAZ0769200OtherBLUE CROSS BLUE SHIELD #
AZZ102475OtherMEDICARE GROUP PTAN
AZZ102475OtherMEDICARE GROUP PTAN