Provider Demographics
NPI:1285669069
Name:IBANEZ, JOE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:DAVID
Last Name:IBANEZ
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 4677
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:713-481-3544
Practice Address - Fax:713-432-0221
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6434207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87880JOtherBCBS-STMC
TX220030493OtherTRAVELER'S MEDICARE
TXP01188589OtherRAILROAD MEDICARE - WHARTON MEM HERM
TX116811403Medicaid
TX116811404Medicaid
TX116811405OtherMEDICAID STMC
TX8DF121OtherBCBS
TX8G9909OtherBCBS
TX116811407Medicaid
TXP00335704OtherRAILROAD MEDICARE
TX220030493OtherTRAVELER'S MEDICARE
TX116811407Medicaid
TXP01188589OtherRAILROAD MEDICARE - WHARTON MEM HERM
TX8G9909OtherBCBS