Provider Demographics
NPI:1225104235
Name:THIBERT, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THIBERT
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0670
Mailing Address - Country:US
Mailing Address - Phone:541-389-7741
Mailing Address - Fax:541-278-8376
Practice Address - Street 1:929 SW SIMPSON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3599
Practice Address - Country:US
Practice Address - Phone:541-389-7741
Practice Address - Fax:541-278-8376
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5190415-1205207Q00000X
WAMD00048052207Q00000X
ORMD169232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878073Medicare PIN