Basic Information
| Provider Information | |||||||||
| NPI: | 1689606782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUBOKU-METZGER | ||||||||
| FirstName: | ALBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2835 BRANDYWISE RD | ||||||||
| Address2: | #3A | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
| FaxNumber: | 6785471494 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 VILLAGE CENTER PARKWAY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
| FaxNumber: | 6785471494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 027254 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00303707C | 05 | GA | MEDICAID |