Provider Demographics
NPI:1902848989
Name:TUBBS, GARY ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ARTHUR
Last Name:TUBBS
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 4979
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4979
Mailing Address - Country:US
Mailing Address - Phone:208-322-7284
Mailing Address - Fax:
Practice Address - Street 1:6023 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-322-7284
Practice Address - Fax:208-322-6504
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002643400Medicaid
ID1122961Medicare ID - Type Unspecified
IDE17779Medicare UPIN