Healthcare Provider Details

I. General information

NPI: 1720242357
Provider Name (Legal Business Name): DANIEL S GIBBONS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 DURHAM RD STE 101
FREEPORT ME
04032-6796
US

IV. Provider business mailing address

460 AUGUSTA RD APT B
TOPSHAM ME
04086-5728
US

V. Phone/Fax

Practice location:
  • Phone: 207-865-6655
  • Fax: 207-865-6655
Mailing address:
  • Phone: 207-865-6655
  • Fax: 207-865-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2222
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number2222
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: