Provider Demographics
NPI:1821185091
Name:TEAGUE, AUDIE M (OD)
Entity Type:Individual
Prefix:DR
First Name:AUDIE
Middle Name:M
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 STREET 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
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103598722Medicaid
AR49758Medicare PIN
ART20336Medicare UPIN