Provider Demographics
NPI:1265497424
Name:IBARRA, GUILLERMO (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:IBARRA
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:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-0807
Mailing Address - Country:US
Mailing Address - Phone:913-248-9693
Mailing Address - Fax:913-248-9383
Practice Address - Street 1:8629 BLUEJACKET ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66214-1604
Practice Address - Country:US
Practice Address - Phone:913-677-0500
Practice Address - Fax:913-677-5243
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-162492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSK933668Medicare ID - Type Unspecified
C50321Medicare UPIN