Healthcare Provider Details

I. General information

NPI: 1619056355
Provider Name (Legal Business Name): ROBERT W GIBBONS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 MINERAL SPRING AVE
NORTH PROVIDENCE RI
02911
US

IV. Provider business mailing address

250 WAMPANOG TRAIL SUITE 205
EAST PROVIDENCE RI
02915
US

V. Phone/Fax

Practice location:
  • Phone: 401-231-0500
  • Fax: 401-231-3312
Mailing address:
  • Phone: 401-431-0283
  • Fax: 401-438-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM00189
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: