Provider Demographics
NPI:1417520081
Name:BIBEAU, ROBERT (DOM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BIBEAU
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7717 ROBERTS ST. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5250
Mailing Address - Country:US
Mailing Address - Phone:505-681-5603
Mailing Address - Fax:
Practice Address - Street 1:7820 PAN AMERICAN FWY, NE
Practice Address - Street 2:STE 3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4655
Practice Address - Country:US
Practice Address - Phone:505-828-9642
Practice Address - Fax:505-828-9191
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1275171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
15201639OtherCAQH