Healthcare Provider Details

I. General information

NPI: 1396733283
Provider Name (Legal Business Name): GARY E GIBLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 CAJA DEL ORO GRANT RD
SANTA FE NM
87507-3279
US

IV. Provider business mailing address

2145 CAJA DEL ORO GRANT RD
SANTA FE NM
87507-3279
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-3195
  • Fax: 505-424-5699
Mailing address:
  • Phone: 505-438-3195
  • Fax: 505-424-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95243
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: