MEDICARE: DR. MARY-LIBERTY Y GIBBS D.O.

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	207R00000X	Internal Medicine Physician	0102203392	VA
2	207Q00000X	Family Medicine Physician	DO2536	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DO2536	OTHER	NV	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235425448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY-LIBERTY Y GIBBS D.O.

Provider Business Mailing Address
First Line	:	10624 S EASTERN AVE
Second Line	:	# A-955
City	:	HENDERSON
State	:	NV
Zip	:	89052-2982
Country	:	US
Telephone Number	:	702-407-7700
Fax Number	:	702-407-7016

Provider Business Practice Location Address
First Line	:	6210 N DURANGO DR BLDG 11
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-3916
Country	:	US
Telephone Number	:	702-940-1540
Fax Number	:	702-940-1541

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

Provider Enumeration Date	:	06/26/2011
Last Update Date	:	02/25/2021

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