Provider Demographics
NPI:1679675383
Name:GIBB, RANDAL BOYD (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:BOYD
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:820 S WOODLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:UT
Practice Address - Zip Code:84653-2030
Practice Address - Country:US
Practice Address - Phone:801-372-8314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1650121205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870281028RG2OtherEMIA
UT10-00362OtherUNITED HEALTHCARE
UT107006654103OtherIHC
UT233116OtherALTIUS
UT36245OtherDMBA
UT81445OtherPEHP
UTP00215615OtherPALMETTO
UT870281028RG2OtherEMIA
UT870281028RG2OtherEMIA
UT107006654103OtherIHC
UTD07478Medicare UPIN