Basic Information
| Provider Information | |||||||||
| NPI: | 1720578685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIBEAU | ||||||||
| FirstName: | LUC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4612 OUTER LOOP | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402193971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028044811 | ||||||||
| FaxNumber: | 5023848652 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 DIXIE HWY STE 130 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402162995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446923338 | ||||||||
| FaxNumber: | 5028057149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2018 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 07001367A | IN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 269120 | KY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07001367A | 01 | IN | MEDICAL LICENSE | OTHER | 269120 | 01 | KY | MEDICAL LICENSE | OTHER |