Provider Demographics
NPI:1922199413
Name:BIBB, RICHARD CLARK (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLARK
Last Name:BIBB
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 1:2820 JUDSON CIR.
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1065
Mailing Address - Country:US
Mailing Address - Phone:505-920-2915
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:SUITE D
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-327-4796
Practice Address - Fax:505-566-0381
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE04022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89654064Medicaid
NMNMAAA1726OtherMEDICARE ID TYPE UNSPECIFIED
TX035245201Medicaid
TX0P137Medicare ID - Type Unspecified