Healthcare Provider Details

I. General information

NPI: 1316073141
Provider Name (Legal Business Name): DWAYNE L GIBBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W MAPLE ST
FARMINGTON NM
87401-6113
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6300
  • Fax: 505-609-6301
Mailing address:
  • Phone: 505-324-2098
  • Fax: 505-324-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number91-205
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: