1699748772 NPI number — DANIEL L GIBSON DO

Table of content: DANIEL L GIBSON DO (NPI 1699748772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699748772 NPI number — DANIEL L GIBSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
DANIEL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699748772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1107
Provider Second Line Business Mailing Address:
HEALTH BRANCH WEST
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65102-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-893-7848
Provider Business Mailing Address Fax Number:
573-893-1984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3308 W EDGEWOOD DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65109-6891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-893-7848
Provider Business Practice Location Address Fax Number:
573-893-1984
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2000169649 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 440546366 . This is a "UNITED HEALTCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 174322 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 245920210 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2623345 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 534157 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00026725 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: H70166 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2095433 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com