Provider Demographics
NPI:1811074461
Name:GIBBON, THOMAS L (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:GIBBON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:114 DOWNEY PL
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1640
Practice Address - Country:US
Practice Address - Phone:573-885-3358
Practice Address - Fax:573-885-3361
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO106716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO080102906OtherRR MCR
MO1811074461Medicaid
MO431560263OtherTRICARE
MO431560263OtherTRICARE