Provider Demographics
NPI:1053594275
Name:TERESA J TIBBETTS M D LLC
Entity type:Organization
Organization Name:TERESA J TIBBETTS M D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-4233
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 A106
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ474429Medicaid
AZ0769200OtherBCBS AZ
2Z2286OtherHEALTH NET
DD0854OtherRAILROAD MEDICARE
AZ474429Medicaid
DD0854OtherRAILROAD MEDICARE