=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679675383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDAL BOYD GIBB MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 S WOODLAND HILLS DR
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84653-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-372-8314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 N 500 W CREDENTIALING DEPARTMENT
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-354-8225
-----------------------------------------------------
Fax | 801-418-0941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 1650121205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------