Healthcare Provider Details

I. General information

NPI: 1275947970
Provider Name (Legal Business Name): JORGE IBARRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10711 BEXLEY DR
HOUSTON TX
77099-1803
US

IV. Provider business mailing address

10711 BEXLEY DR
HOUSTON TX
77099-1803
US

V. Phone/Fax

Practice location:
  • Phone: 281-857-3781
  • Fax: 281-564-5694
Mailing address:
  • Phone: 281-857-3781
  • Fax: 281-564-5694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: