Provider Demographics
NPI:1649030156
Name:TUBBERVILLE, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:TUBBERVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 W NEW HOPE RD APT C1
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7586
Mailing Address - Country:US
Mailing Address - Phone:321-525-2741
Mailing Address - Fax:
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-741-9200
Practice Address - Fax:540-741-9201
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program