Provider Demographics
NPI:1245485994
Name:DWAYNE L GIBBS MD PC
Entity type:Organization
Organization Name:DWAYNE L GIBBS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-324-2098
Mailing Address - Street 1:PO BOX 1919
Mailing Address - Street 2:SUITE C
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-1919
Mailing Address - Country:US
Mailing Address - Phone:505-324-2098
Mailing Address - Fax:505-324-6454
Practice Address - Street 1:630 W MAPLE ST
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6113
Practice Address - Country:US
Practice Address - Phone:505-324-2098
Practice Address - Fax:505-324-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53885Medicaid