Provider Demographics
NPI:1659352441
Name:GIBBONS, MICHAEL CHARLES (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50469
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0469
Mailing Address - Country:US
Mailing Address - Phone:530-778-0200
Mailing Address - Fax:530-778-0200
Practice Address - Street 1:2480 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-6780
Practice Address - Country:US
Practice Address - Phone:503-763-3525
Practice Address - Fax:503-763-3526
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5467820001OtherMEDICARE DME NUMBER
OR227892Medicaid
ORR105769Medicare ID - Type Unspecified