Provider Demographics
NPI:1720242357
Name:GIBBONS, DANIEL S (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:460 AUGUSTA RD APT B
Mailing Address - Street 2:
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-5728
Mailing Address - Country:US
Mailing Address - Phone:207-865-6655
Mailing Address - Fax:207-865-6653
Practice Address - Street 1:23 DURHAM RD STE 101
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6796
Practice Address - Country:US
Practice Address - Phone:207-865-6655
Practice Address - Fax:207-865-6655
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2222207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH1720242357Medicaid