MEDICARE: ROY RAYMOND GIBSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1130289934	UT
2	152W00000X	Optometrist	1130288904	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1737499	OTHER	UT	FIRST HEALTH NETWORK
2	589803	OTHER	UT	DMBA
3	11445324	OTHER	UT	CAQH
4	81820	OTHER	UT	PEHP

General Provider Information

NPI Number	:	1104816743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY RAYMOND GIBSON O.D.

Provider Business Mailing Address
First Line	:	5690 S 3750 W
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-8161
Country	:	US
Telephone Number	:	801-985-4141
Fax Number	:	801-985-4242

Provider Business Practice Location Address
First Line	:	4949 S 900 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3777
Country	:	US
Telephone Number	:	801-621-0480
Fax Number	:	801-612-3485

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/08/2007

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