Healthcare Provider Details

I. General information

NPI: 1376637611
Provider Name (Legal Business Name): RICHARD A GIBULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MORNING LIGHT CT
CORNVILLE AZ
86325-5003
US

IV. Provider business mailing address

1020 S MORNING LIGHT CT
CORNVILLE AZ
86325-5003
US

V. Phone/Fax

Practice location:
  • Phone: 941-979-7007
  • Fax:
Mailing address:
  • Phone: 941-979-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41961
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: