Provider Demographics
NPI:1669560850
Name:HIBBARD, ARLIS WAYNE (MD)
Entity type:Individual
Prefix:
First Name:ARLIS
Middle Name:WAYNE
Last Name:HIBBARD
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 1:409 RUSSELL BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-560-2595
Mailing Address - Fax:936-560-5621
Practice Address - Street 1:409 RUSSELL BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-560-2595
Practice Address - Fax:936-560-5621
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6742207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B23476Medicare UPIN
00HW44Medicare ID - Type Unspecified