Provider Demographics
NPI:1669512471
Name:FIELDS GRUBE, AUDREY EILEEN (OD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:EILEEN
Last Name:FIELDS GRUBE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:EILEEN
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1514 BUCCANEER PL
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-8982
Mailing Address - Country:US
Mailing Address - Phone:701-250-6820
Mailing Address - Fax:
Practice Address - Street 1:107 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3129
Practice Address - Country:US
Practice Address - Phone:701-751-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND599152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist