Provider Demographics
NPI:1609854975
Name:NIEBAUM, LOWELL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:THOMAS
Last Name:NIEBAUM
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 1:2800 E DESERT INN RD
Mailing Address - Street 2:#100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3608
Mailing Address - Country:US
Mailing Address - Phone:702-731-1616
Mailing Address - Fax:702-731-0741
Practice Address - Street 1:2800 E DESERT INN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3608
Practice Address - Country:US
Practice Address - Phone:702-731-1616
Practice Address - Fax:702-731-0741
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2576207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2576OtherBXBS
200002160OtherR.R. MEDICARE
NV2002357Medicaid
4297372OtherAETNA
E97923Medicare UPIN
NV2002357Medicaid