MEDICARE: VAN MOORE OD AND DAVID R. GIBSON OD

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821208653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN MOORE OD AND DAVID R. GIBSON OD

Provider Business Mailing Address
First Line	:	1018 N 1ST ST
Second Line	:
City	:	LAMESA
State	:	TX
Zip	:	79331-5306
Country	:	US
Telephone Number	:	806-872-8440
Fax Number	:	806-872-7875

Provider Business Practice Location Address
First Line	:	1018 N 1ST ST
Second Line	:
City	:	LAMESA
State	:	TX
Zip	:	79331-5306
Country	:	US
Telephone Number	:	806-747-1635
Fax Number	:	806-747-5499

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. DAVID ROGER GIBSON
Credential	:	O.D.
Telephone Number	:	806-747-1635

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	05/30/2008

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