Basic Information
| Provider Information | |||||||||
| NPI: | 1770521734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIEBUYCK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 W ROUTE 66 | ||||||||
| Address2: | # 202 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | 6269639543 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 W ROUTE 66 | ||||||||
| Address2: | # 202 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | 6269639543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A78684 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A786840 | 05 | CA | MEDICAID |