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General NPI Number Information
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NPI Number | 1245485994
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Entity Type | Organization
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Legal Business Name | DWAYNE L GIBBS MD PC
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Dates
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Enumeration Date | 11/21/2008
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Last Update Date | 12/06/2012
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Provider Practice Location Address
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Address Line | 630 W MAPLE ST SUITE A
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City | FARMINGTON
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State | NM
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Zip | 87401-6113
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Country | US
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Telephone | 505-324-2098
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Fax | 505-324-6454
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Provider Business Mailing Address
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Address Line | PO BOX 1919 SUITE C
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City | FARMINGTON
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State | NM
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Zip | 87499-1919
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Country | US
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Telephone | 505-324-2098
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Fax | 505-324-6454
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Authorized Official
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Title or Position | OWNER
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Name | DR. DWAYNE L GIBBS
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Credential | M.D.
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Telephone | 505-324-2098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 91-205
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License Number State | NM
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