Provider Demographics
NPI:1821113804
Name:GIBBONS EYE CLINIC, OPTOMETRISTS, P.A.
Entity Type:Organization
Organization Name:GIBBONS EYE CLINIC, OPTOMETRISTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:NEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-689-1441
Mailing Address - Street 1:120 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1230
Mailing Address - Country:US
Mailing Address - Phone:763-689-1441
Mailing Address - Fax:763-689-3925
Practice Address - Street 1:120 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1230
Practice Address - Country:US
Practice Address - Phone:763-689-1441
Practice Address - Fax:763-689-3925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1978152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN987323600Medicaid
MNT70712Medicare UPIN
MN0591670001Medicare PIN
MN987323600Medicaid
MN0591670001Medicare NSC
MN419000525Medicare ID - Type Unspecified