Provider Demographics
NPI:1326310335
Name:TIBAY, JOSEPH R (RD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:R
Last Name:TIBAY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 SOUTH 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603
Mailing Address - Country:US
Mailing Address - Phone:541-882-1487
Mailing Address - Fax:541-880-5590
Practice Address - Street 1:330 CHILOQUIN BLVD
Practice Address - Street 2:
Practice Address - City:CHILOQUIN
Practice Address - State:OR
Practice Address - Zip Code:97624-6747
Practice Address - Country:US
Practice Address - Phone:541-882-1487
Practice Address - Fax:541-783-3237
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR966795133V00000X
966795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500735399Medicaid
966795OtherCDR REGISTRATION