Healthcare Provider Details

I. General information

NPI: 1063418176
Provider Name (Legal Business Name): JOHN GIBBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 01/10/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number189632
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA09547000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: