Provider Demographics
NPI:1235332198
Name:TIBBS, BRIAN MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:TIBBS
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 1:8230 WALNUT HILL LN STE 320
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4481
Mailing Address - Country:US
Mailing Address - Phone:214-369-5432
Mailing Address - Fax:214-369-5591
Practice Address - Street 1:8230 WALNUT HILL LN STE 320
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4481
Practice Address - Country:US
Practice Address - Phone:214-369-5432
Practice Address - Fax:214-369-5591
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005863208600000X
TXP94742086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175956001Medicaid
MO431560263OtherTRICARE WEST
MO20744506Medicaid
MO132680045Medicare PIN
MOL76F350Medicare PIN
MO20744506Medicaid