Provider Demographics
NPI:1750624979
Name:GIBBY, CONRAD CURTIS (MD)
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:CURTIS
Last Name:GIBBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4745
Mailing Address - Country:US
Mailing Address - Phone:801-229-2002
Mailing Address - Fax:
Practice Address - Street 1:3152 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4745
Practice Address - Country:US
Practice Address - Phone:801-229-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-06
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9724223-12052085R0202X, 2085R0204X
AZ599342085R0204X
CAA1752972085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1750624979OtherBCBS OF AZ
AZ1750624979Medicaid
AZZ237130OtherMEDICARE