Provider Demographics
NPI:1871569632
Name:TIBBELS, CHARLES KELLEY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
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 1:1821 S FM 51
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3715
Mailing Address - Country:US
Mailing Address - Phone:940-233-6929
Mailing Address - Fax:877-892-4569
Practice Address - Street 1:1821 S FM 51
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3715
Practice Address - Country:US
Practice Address - Phone:940-233-6929
Practice Address - Fax:877-892-4569
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080094585OtherRAILROAD MEDICARE
TX136230301Medicaid
TX8EG149OtherBCBSTX
TX136230311Medicaid
TXP00362520OtherRAILROAD MEDICARE-AMC
TXB268981Medicare UPIN
TX81Z887Medicare PIN
TX8EG149OtherBCBSTX