Provider Demographics
NPI:1225075377
Name:TRIBELHORN, DWIGHT R (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:R
Last Name:TRIBELHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 SISKIYOU BLVD
Mailing Address - Street 2:#B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8131
Mailing Address - Country:US
Mailing Address - Phone:541-773-3636
Mailing Address - Fax:541-773-4643
Practice Address - Street 1:2959 SISKIYOU BLVD
Practice Address - Street 2:#B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8131
Practice Address - Country:US
Practice Address - Phone:541-773-3636
Practice Address - Fax:541-245-9147
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18428174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR056973Medicaid
OR056973Medicaid
OR104893Medicare ID - Type UnspecifiedMEDICARD
OR070014131Medicare PIN