Healthcare Provider Details

I. General information

NPI: 1316917446
Provider Name (Legal Business Name): CHARLES CLARENCE GIBBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 COUNTY ROUTE 47
SARANAC LAKE NY
12983-5403
US

IV. Provider business mailing address

PO BOX 890
SARANAC LAKE NY
12983-0890
US

V. Phone/Fax

Practice location:
  • Phone: 518-891-2660
  • Fax: 518-891-2663
Mailing address:
  • Phone: 518-891-2660
  • Fax: 518-891-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number136590
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: