Healthcare Provider Details

I. General information

NPI: 1043209836
Provider Name (Legal Business Name): ROBERT J JIBBEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 BUSINESS HWY 60 W STE A1
DEXTER MO
63841
US

IV. Provider business mailing address

PO BOX 472
DEXTER MO
63841-0472
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-8447
  • Fax:
Mailing address:
  • Phone: 573-624-8447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5B81
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOR5B81
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: