Provider Demographics
NPI:1699890749
Name:IBSEN, MICHELLE J (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:IBSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:214-775-4502
Practice Address - Street 1:3470 LANDERS RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2541
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC72942083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AA03G344Medicare UPIN
AR5G344Medicare PIN