Provider Demographics
NPI:1043894132
Name:IBA, BRADY W (DO)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:W
Last Name:IBA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 WIND CALL LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-0826
Mailing Address - Country:US
Mailing Address - Phone:817-705-9625
Mailing Address - Fax:
Practice Address - Street 1:3024 WIND CALL LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-0826
Practice Address - Country:US
Practice Address - Phone:817-705-9625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK83682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry