Basic Information
| Provider Information | |||||||||
| NPI: | 1639407448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBANEZ | ||||||||
| FirstName: | NOEL | ||||||||
| MiddleName: | DESANTOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16740 DAVIDSON CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | DAVIDSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280368746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044442400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084F0202X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0005X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurodevelopmental Disabilities | 2084P0015X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0802X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084S0012X | 2010-01897 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084P0800X | 2010-01897 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.