Provider Demographics
NPI:1457485880
Name:NIBO, DANIEL E (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:NIBO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6223 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-1614
Mailing Address - Country:US
Mailing Address - Phone:770-997-0047
Mailing Address - Fax:770-997-0390
Practice Address - Street 1:6223 CHURCH ST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-1614
Practice Address - Country:US
Practice Address - Phone:770-997-0047
Practice Address - Fax:770-997-0390
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00891239AMedicaid
GAH31499Medicare UPIN
GA08BBTVNMedicare ID - Type UnspecifiedMEDICARE NUMBER