Healthcare Provider Details

I. General information

NPI: 1225104235
Provider Name (Legal Business Name): MARK THIBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 NW BEAVER ST STE 101
PRINEVILLE OR
97754-1802
US

IV. Provider business mailing address

PO BOX 4228
PORTLAND OR
97208-4228
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-3005
  • Fax: 541-383-1883
Mailing address:
  • Phone: 541-383-3005
  • Fax: 541-383-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD169232
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5190415-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00048052
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD169232
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: