Provider Demographics
NPI:1891752382
Name:GIFFORD, GERALD KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:KEVIN
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 E HOPI AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6266
Mailing Address - Country:US
Mailing Address - Phone:480-813-2906
Mailing Address - Fax:480-813-2916
Practice Address - Street 1:2716 E HOPI AVENUE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6266
Practice Address - Country:US
Practice Address - Phone:480-813-2906
Practice Address - Fax:480-813-2916
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4996111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ498502Medicaid
AZ498502Medicaid