Healthcare Provider Details

I. General information

NPI: 1811074461
Provider Name (Legal Business Name): THOMAS L. GIBBON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 DOWNEY PL
CUBA MO
65453-1640
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 573-885-3358
  • Fax: 573-885-3361
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106716
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: