Provider Demographics
NPI:1720080427
Name:GIBBS, DANIEL M (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:M
Last Name:GIBBS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 LLOYD CTR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1315
Mailing Address - Country:US
Mailing Address - Phone:503-494-8305
Mailing Address - Fax:503-418-5339
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:SUITE 8 (MAIL CODE CH8C)
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD150052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044313Medicaid
WA8130437Medicaid
ORE28576Medicare UPIN
OR044313Medicaid