Provider Demographics
NPI:1679663884
Name:TIBLE, PRUDENCIO GALVEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCIO
Middle Name:GALVEZ
Last Name:TIBLE
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 18936
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118
Mailing Address - Country:US
Mailing Address - Phone:206-725-8043
Mailing Address - Fax:206-760-1359
Practice Address - Street 1:5023 S BARTON PLACE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118
Practice Address - Country:US
Practice Address - Phone:206-725-8043
Practice Address - Fax:206-760-1359
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022189208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1035013Medicaid
WA1035013Medicaid