Provider Demographics
NPI:1073823555
Name:GIBBONS, DEREK D (DC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:D
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 TROY TOWN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2341
Mailing Address - Country:US
Mailing Address - Phone:937-703-9328
Mailing Address - Fax:937-703-9329
Practice Address - Street 1:50 TROY TOWN DR
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2341
Practice Address - Country:US
Practice Address - Phone:937-703-9328
Practice Address - Fax:937-703-9329
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4314051Medicare UPIN