Provider Demographics
NPI:1659466019
Name:GIBB, ERIC NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:NICHOLAS
Last Name:GIBB
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 937
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-0937
Mailing Address - Country:US
Mailing Address - Phone:719-207-1951
Mailing Address - Fax:888-516-1373
Practice Address - Street 1:907 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-2218
Practice Address - Country:US
Practice Address - Phone:719-207-1951
Practice Address - Fax:888-516-1373
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01355106Medicaid
D4358Medicare ID - Type Unspecified
CO01355106Medicaid