Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 2002005863 | MO |
N | 208600000X | Surgeon | 2002005863 | MO |
Y | 208200000X | Surgeon | P9474 | TX |
Y | 208600000X | Surgeon | P9474 | TX |
N | 2086S0102X | Surgical Critical Care | P9474 | TX |
NPI | 1235332198 |
---|---|
Provider Name | Brian Matthew Tibbs |
First Address | Dallas, TX 75231-4481 |
Second Address | Dallas, TX 75231-4481 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2007 |
Last Update Date | 30/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
175956001 | (05) | AR |
20744506 | (05) | MO |
431560263 | TRICARE WEST (01) | MO |