Provider Demographics
NPI:1538220132
Name:TIBBITS, SCOTT J (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:TIBBITS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:360-493-4069
Mailing Address - Fax:
Practice Address - Street 1:3425 ENSIGN RD NE
Practice Address - Street 2:SUITE 220
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5425
Practice Address - Country:US
Practice Address - Phone:360-491-1112
Practice Address - Fax:360-493-8160
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030644207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA539787389OtherCIGNA HEALTH INSURANCE
WA8148694Medicaid
WA0149441OtherLABOR & INDUSTRIES
WA110221313OtherRAILROAD MEDICARE
WA3911TIOtherCOUNTY
WA0149441OtherLABOR & INDUSTRIES
WAE92466Medicare UPIN