Provider Demographics
NPI:1508804477
Name:GIBSON, RICHARD F (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:GIBSON
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 13994
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-0994
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:203-215-6644
Practice Address - Street 1:545 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2237
Practice Address - Country:US
Practice Address - Phone:503-215-9700
Practice Address - Fax:503-215-9701
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR079884Medicaid
OR80120791OtherRR MEDICARE
OR079884Medicaid
OR80120791OtherRR MEDICARE