Provider Demographics
NPI:1609851492
Name:HIEBERT, TIMOTHY C (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:HIEBERT
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:PO BOX 3590
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-3590
Mailing Address - Country:US
Mailing Address - Phone:228-474-6111
Mailing Address - Fax:361-576-4219
Practice Address - Street 1:3418 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5102
Practice Address - Country:US
Practice Address - Phone:228-474-6111
Practice Address - Fax:225-474-6113
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMD16489207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121256Medicaid
43-2030497OtherEIN
F73268Medicare UPIN
43-2030497OtherEIN