Provider Demographics
NPI:1043761604
Name:PHILIP, GIBI
Entity Type:Individual
Prefix:
First Name:GIBI
Middle Name:
Last Name:PHILIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GIBI
Other - Middle Name:
Other - Last Name:TOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2117 MAGIC MANTLE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056
Mailing Address - Country:US
Mailing Address - Phone:469-767-6678
Mailing Address - Fax:
Practice Address - Street 1:2117 MAGIC MANTLE DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-4239
Practice Address - Country:US
Practice Address - Phone:469-767-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230032164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse