Provider Demographics
NPI:1073680328
Name:IBARRA, DAN RICHARD (PT)
Entity Type:Individual
Prefix:
First Name:DAN RICHARD
Middle Name:
Last Name:IBARRA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 NW STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-5653
Mailing Address - Country:US
Mailing Address - Phone:541-957-5825
Mailing Address - Fax:541-957-5801
Practice Address - Street 1:2395 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-5653
Practice Address - Country:US
Practice Address - Phone:541-957-5825
Practice Address - Fax:541-957-5801
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04250Medicare UPIN
OR107890Medicare ID - Type Unspecified