Healthcare Provider Details

I. General information

NPI: 1972610210
Provider Name (Legal Business Name): ROBERT D GIBBS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 KERN WAY
YAKIMA WA
98902-7803
US

IV. Provider business mailing address

PO BOX 1506
CHEHALIS WA
98532-0409
US

V. Phone/Fax

Practice location:
  • Phone: 509-966-1356
  • Fax: 509-966-5101
Mailing address:
  • Phone: 360-242-3008
  • Fax: 360-807-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003294
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: