Provider Demographics
NPI:1215904222
Name:TIBBELS, JASON KELLEY (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KELLEY
Last Name:TIBBELS
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 1:2250 S FM 51 STE 400
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3767
Mailing Address - Country:US
Mailing Address - Phone:640-627-1011
Mailing Address - Fax:
Practice Address - Street 1:2250 S FM 51 STE 400
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3767
Practice Address - Country:US
Practice Address - Phone:640-627-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156092202Medicaid
TX156092202Medicaid
TXH72917Medicare UPIN