Provider Demographics
NPI:1386833705
Name:GIBSON, MONIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5306
Mailing Address - Country:US
Mailing Address - Phone:505-863-3120
Mailing Address - Fax:
Practice Address - Street 1:610 N 5TH ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5306
Practice Address - Country:US
Practice Address - Phone:505-863-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG78318Medicare UPIN