Provider Demographics
NPI:1023194396
Name:GIBAS, RICHARD JOSEPH SR (DN)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:GIBAS
Suffix:SR
Gender:M
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-1149
Mailing Address - Country:US
Mailing Address - Phone:217-351-4000
Mailing Address - Fax:217-356-3991
Practice Address - Street 1:1408 ANTHONY DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-1149
Practice Address - Country:US
Practice Address - Phone:217-351-4000
Practice Address - Fax:217-356-3991
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01025336OtherBCBS OF IL