Provider Demographics
NPI:1457366858
Name:TIBREWALA, SUSHILKUMAR MAHABIRPRASAD (MD)
Entity Type:Individual
Prefix:MR
First Name:SUSHILKUMAR
Middle Name:MAHABIRPRASAD
Last Name:TIBREWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SUSHIL
Other - Middle Name:
Other - Last Name:TIBREWALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:24 PINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5410
Mailing Address - Country:US
Mailing Address - Phone:618-998-8885
Mailing Address - Fax:618-998-8886
Practice Address - Street 1:3301 PATRIOT CT
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3782
Practice Address - Country:US
Practice Address - Phone:618-998-8885
Practice Address - Fax:618-998-8886
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073571207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073571Medicaid
IL833199720OtherAETNA
IL0010023397OtherBLUE CROSS/BLUE SHIELD