Provider Demographics
NPI:1881328870
Name:GIBBS, KAITLIN MICHELLE (OD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELLE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 KENT RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1867
Mailing Address - Country:US
Mailing Address - Phone:238-369-5597
Mailing Address - Fax:
Practice Address - Street 1:22395 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6016
Practice Address - Country:US
Practice Address - Phone:734-324-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist