Provider Demographics
NPI:1760478564
Name:TIBALDI, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:TIBALDI
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8330
Mailing Address - Fax:702-877-8312
Practice Address - Street 1:2316 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2149
Practice Address - Country:US
Practice Address - Phone:702-877-8330
Practice Address - Fax:702-877-8312
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19721207RG0100X
OH35065820207RG0100X
NV11661207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760478564Medicaid
OH0151302Medicaid
WV6000016000Medicaid
NV1760478564Medicaid
WVG03990Medicare UPIN
OH0151302Medicaid
WV0783064Medicare ID - Type Unspecified
OH0783066Medicare ID - Type Unspecified