Healthcare Provider Details

I. General information

NPI: 1659466019
Provider Name (Legal Business Name): ERIC NICHOLAS GIBB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 S MAIN ST
BUENA VISTA CO
81211-2218
US

IV. Provider business mailing address

PO BOX 937
BUENA VISTA CO
81211-0937
US

V. Phone/Fax

Practice location:
  • Phone: 719-207-1951
  • Fax: 888-516-1373
Mailing address:
  • Phone: 719-207-1951
  • Fax: 888-516-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35510
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: