Provider Demographics
NPI:1275849309
Name:PRESTON FAMILY MEDICINE
Entity Type:Organization
Organization Name:PRESTON FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:GIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:208-852-3755
Mailing Address - Street 1:45 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1325
Mailing Address - Country:US
Mailing Address - Phone:208-852-3755
Mailing Address - Fax:208-852-3774
Practice Address - Street 1:45 N 1ST E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1325
Practice Address - Country:US
Practice Address - Phone:208-852-3755
Practice Address - Fax:208-852-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE69414Medicare UPIN