Healthcare Provider Details

I. General information

NPI: 1881082121
Provider Name (Legal Business Name): IDEAL INTERNAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 SARATOGA BLVD SUITE 475
CORPUS CHRISTI TX
78414-4103
US

IV. Provider business mailing address

5920 SARATOGA BLVD SUITE 475
CORPUS CHRISTI TX
78414-4103
US

V. Phone/Fax

Practice location:
  • Phone: 361-654-2064
  • Fax: 361-654-2068
Mailing address:
  • Phone: 361-654-2064
  • Fax: 361-654-2068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL0290
License Number StateTX

VIII. Authorized Official

Name: MICHELE IBANEZ
Title or Position: OWNER
Credential: MD
Phone: 361-654-2064