Healthcare Provider Details

I. General information

NPI: 1245468404
Provider Name (Legal Business Name): MICHAEL TIBBETTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 DEL PRADO BLVD S
CAPE CORAL FL
33904-7165
US

IV. Provider business mailing address

P.O. BOX 101468
CAPE CORAL FL
33910-1468
US

V. Phone/Fax

Practice location:
  • Phone: 239-542-2020
  • Fax: 239-541-1492
Mailing address:
  • Phone: 239-542-2020
  • Fax: 239-541-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME115062
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME115062
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: