1417520081 NPI number — DR. ROBERT BIBEAU DOM

Table of content: DR. ROBERT BIBEAU DOM (NPI 1417520081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417520081 NPI number — DR. ROBERT BIBEAU DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIBEAU
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417520081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7717 ROBERTS ST. NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-5250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-681-5603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7820 PAN AMERICAN FWY, NE
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-4655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-828-9642
Provider Business Practice Location Address Fax Number:
505-828-9191
Provider Enumeration Date:
07/21/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  DOM1275 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15201639 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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