Provider Demographics
NPI:1932282415
Name:GIBBONS, THOMAS JOSEPH (OD - OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:OD - OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-4280
Mailing Address - Country:US
Mailing Address - Phone:775-882-5963
Mailing Address - Fax:775-882-5371
Practice Address - Street 1:444 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4280
Practice Address - Country:US
Practice Address - Phone:775-882-5963
Practice Address - Fax:775-882-5371
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002513505Medicaid
NVT67215Medicare UPIN
NV002513505Medicaid
NVFG192AMedicare PIN