Provider Demographics
NPI:1063859155
Name:BIBO, ANDREW L (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:BIBO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 SHEPARD LN
Mailing Address - Street 2:STE 105
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2973
Mailing Address - Country:US
Mailing Address - Phone:801-923-3145
Mailing Address - Fax:
Practice Address - Street 1:991 SHEPARD LN
Practice Address - Street 2:STE 105
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2973
Practice Address - Country:US
Practice Address - Phone:801-923-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8674084-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000078765Medicare UPIN