Healthcare Provider Details

I. General information

NPI: 1063481331
Provider Name (Legal Business Name): JOSE L IBARRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 08/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5561 E KINGS CANYON RD
FRESNO CA
93727-4528
US

IV. Provider business mailing address

5561 E KINGS CANYON RD
FRESNO CA
93727-4528
US

V. Phone/Fax

Practice location:
  • Phone: 559-255-0496
  • Fax: 559-253-0510
Mailing address:
  • Phone: 559-255-0496
  • Fax: 559-253-0510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG73482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: