Healthcare Provider Details

I. General information

NPI: 1689652091
Provider Name (Legal Business Name): JAMES CONRAD GIEBINK M.D., F.A.C.R.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 HICKORY ST STE A
MELBOURNE FL
32901-1973
US

IV. Provider business mailing address

1033 FLORIDA AVE S
ROCKLEDGE FL
32955-2138
US

V. Phone/Fax

Practice location:
  • Phone: 321-409-1956
  • Fax: 321-409-1253
Mailing address:
  • Phone: 321-632-0351
  • Fax: 321-361-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberME38372
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME38372
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME38372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: