MEDICARE: PRUDENCIO G TIBLE MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1053417675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUDENCIO G TIBLE MD PC

Provider Business Mailing Address
First Line	:	PO BOX 18936
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118
Country	:	US
Telephone Number	:	206-725-8043
Fax Number	:	206-760-1359

Provider Business Practice Location Address
First Line	:	5023 S BARTON PLACE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118
Country	:	US
Telephone Number	:	206-725-8043
Fax Number	:	206-760-1359

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PRUDENCIO GALVEZ TIBLE
Credential	:	MD
Telephone Number	:	206-725-8043

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	08/22/2020

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