Provider Demographics
NPI:1770540700
Name:KUBALA, TEISHA M (DPM)
Entity type:Individual
Prefix:
First Name:TEISHA
Middle Name:M
Last Name:KUBALA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 W EUGIE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1272
Mailing Address - Country:US
Mailing Address - Phone:602-547-2111
Mailing Address - Fax:602-547-0473
Practice Address - Street 1:8325 W HAPPY VALLEY RD
Practice Address - Street 2:UNIT 105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-4361
Practice Address - Country:US
Practice Address - Phone:602-547-2111
Practice Address - Fax:602-547-0473
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0459213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ45946301Medicaid
AZZ67229Medicare ID - Type UnspecifiedINDIVIDUAL ID
AZZ67228Medicare ID - Type UnspecifiedGROUP ID
AZ45946301Medicaid