Provider Demographics
NPI:1083694905
Name:GIBBS, MARTI RENEE (MD)
Entity Type:Individual
Prefix:
First Name:MARTI
Middle Name:RENEE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTI
Other - Middle Name:RENEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:4222 FAIRBANKS DR
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2811
Practice Address - Country:US
Practice Address - Phone:770-534-6053
Practice Address - Fax:770-534-6695
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10045228OtherAMERIGROUP
GA336006OtherWELLCARE
GA000909015AMedicaid
GA52862399OtherBCBS
GA80177932OtherRR MEDICARE-GRP # CC4177
GA6794635OtherCIGNA
GA0100985OtherUNITED HEALTHCARE
GA7809239OtherAETNA
GA000909015AMedicaid
GA08BBVJQMedicare ID - Type Unspecified