Provider Demographics
NPI:1003132705
Name:TIBBLES, MARK D
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:TIBBLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 S 14TH AVE
Mailing Address - Street 2:#73
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6275
Mailing Address - Country:US
Mailing Address - Phone:928-581-3036
Mailing Address - Fax:
Practice Address - Street 1:2045 S 14TH AVE
Practice Address - Street 2:#73
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6275
Practice Address - Country:US
Practice Address - Phone:928-581-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHAD5886237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist