Provider Demographics
NPI:1912010430
Name:GIBBS, THERESA D (OD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:D
Last Name:GIBBS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 QUINCY LN
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8348
Mailing Address - Country:US
Mailing Address - Phone:518-743-0274
Mailing Address - Fax:
Practice Address - Street 1:3695 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1832
Practice Address - Country:US
Practice Address - Phone:518-623-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006098-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02151339Medicaid
NYCC5075Medicare ID - Type Unspecified