Provider Demographics
NPI:1194820761
Name:GIBEAULT, J DAVID (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:DAVID
Last Name:GIBEAULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30370
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-0370
Mailing Address - Country:US
Mailing Address - Phone:520-722-0777
Mailing Address - Fax:520-290-9713
Practice Address - Street 1:3100 N CAMPBELL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2315
Practice Address - Country:US
Practice Address - Phone:520-577-1200
Practice Address - Fax:520-577-1559
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13121207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249202Medicaid
AZZMD13121Medicare PIN
AZ249202Medicaid