Provider Demographics
NPI:1417901570
Name:TIBBS, MARTHA K (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:K
Last Name:TIBBS
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:PO BOX 2044 DEPT 2600
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-2044
Mailing Address - Country:US
Mailing Address - Phone:901-765-3212
Mailing Address - Fax:901-765-1727
Practice Address - Street 1:5959 PARK AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5200
Practice Address - Country:US
Practice Address - Phone:901-765-3212
Practice Address - Fax:901-765-1727
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0290142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203822408Medicaid
TN3812389Medicaid
MS00118726Medicaid
AR132048001Medicaid
MO203822408Medicaid
TN3812389Medicare ID - Type Unspecified
AR132048001Medicaid