Provider Demographics
NPI:1407864390
Name:WIEBE, BOB J (DO)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:J
Last Name:WIEBE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:J
Other - Last Name:WIEBE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1 E CLARK BASS BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4209
Mailing Address - Country:US
Mailing Address - Phone:918-426-1800
Mailing Address - Fax:918-421-8066
Practice Address - Street 1:1 E CLARK BASS BLVD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4209
Practice Address - Country:US
Practice Address - Phone:918-426-1800
Practice Address - Fax:918-421-8066
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1852207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100258320BMedicaid
OKE16470Medicare UPIN
OK100258320BMedicaid