Provider Demographics
NPI:1275521239
Name:NIEBAUER, MARIVI A (MD)
Entity Type:Individual
Prefix:
First Name:MARIVI
Middle Name:A
Last Name:NIEBAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 312
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-3733
Mailing Address - Fax:276-258-3734
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 312
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-3733
Practice Address - Fax:276-258-3734
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN399372084N0400X
VA01012499562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3334027Medicaid
VAP01200682OtherRAILROAD MEDICARE
VA1275521239Medicaid
TN3334027Medicaid
TNI40618Medicare UPIN