Provider Demographics
NPI:1568625945
Name:TIBBLES, LARRY LYMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LYMAN
Last Name:TIBBLES
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 1:8601 SE 141ST CT
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-5648
Mailing Address - Country:US
Mailing Address - Phone:503-761-4205
Mailing Address - Fax:503-761-4205
Practice Address - Street 1:8601 SE 141ST CT
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-5648
Practice Address - Country:US
Practice Address - Phone:503-761-4205
Practice Address - Fax:503-761-4205
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine