Provider Demographics
NPI:1831182062
Name:GIBBONS, JOSEPH TAIT (OD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:TAIT
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008
Mailing Address - Country:US
Mailing Address - Phone:763-689-1441
Mailing Address - Fax:763-689-3925
Practice Address - Street 1:120 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008
Practice Address - Country:US
Practice Address - Phone:763-689-1441
Practice Address - Fax:763-689-3925
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1978152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T70712Medicare UPIN