Provider Demographics
NPI:1528013851
Name:NIBA, SUH N (MD)
Entity Type:Individual
Prefix:
First Name:SUH
Middle Name:N
Last Name:NIBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GOTHIC RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6565
Mailing Address - Country:US
Mailing Address - Phone:479-474-1100
Mailing Address - Fax:479-474-0069
Practice Address - Street 1:14 GOTHIC RIDGE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6565
Practice Address - Country:US
Practice Address - Phone:479-474-1100
Practice Address - Fax:479-474-0069
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154343001Medicaid
AR154343001Medicaid
I08594Medicare UPIN