Basic Information
| Provider Information | |||||||||
| NPI: | 1710089958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIBEL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122955095 | ||||||||
| FaxNumber: | 8122959403 | ||||||||
| Practice Location | |||||||||
| Address1: | 12546 E US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | LOOGOOTEE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475535220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122955095 | ||||||||
| FaxNumber: | 8122959403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 01043100A | IN | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 01043100A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000644031 | 01 | IN | ANTHEM | OTHER |