Provider Demographics
NPI:1558333625
Name:GIBBONS, RAYMOND J (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:GIBBONS
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-42023207RC0000X
MN26392207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MN060007532OtherRAILROAD MEDICARE
WI35145400Medicaid
SDENROLLEDMedicaid
MN625020300Medicaid
MN060000128Medicare PIN
IAENROLLEDMedicaid