Provider Demographics
NPI:1508029208
Name:TIBAYAN, RESTY T (MD)
Entity Type:Individual
Prefix:
First Name:RESTY
Middle Name:T
Last Name:TIBAYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RESTITUTO
Other - Middle Name:
Other - Last Name:TIBAYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:400 N STEPHANIE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6692
Mailing Address - Country:US
Mailing Address - Phone:702-952-3350
Mailing Address - Fax:702-952-3365
Practice Address - Street 1:2460 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2648
Practice Address - Country:US
Practice Address - Phone:702-822-2000
Practice Address - Fax:702-938-2232
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-35742207RH0003X, 207RH0003X, 207RX0202X
NV17659207RH0003X, 207RH0003X
PAMT192424390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200964510CMedicaid
KS200964510AMedicaid
OK200484440AMedicaid
OK200484440AMedicaid
KS200964510AMedicaid
KSKA3434003Medicare PIN
KS016701010Medicare PIN