Healthcare Provider Details

I. General information

NPI: 1083009468
Provider Name (Legal Business Name): LOGAN GIBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10465 PARK MEADOWS DR
LONE TREE CO
80124-5319
US

IV. Provider business mailing address

6427 OAKBROOK DR
YPSILANTI MI
48197-9494
US

V. Phone/Fax

Practice location:
  • Phone: 303-790-1515
  • Fax:
Mailing address:
  • Phone: 316-304-2976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberDR.0066040
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: