Provider Demographics
NPI:1104816743
Name:GIBSON, ROY RAYMOND (OD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:RAYMOND
Last Name:GIBSON
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 1:5690 S 3750 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8161
Mailing Address - Country:US
Mailing Address - Phone:801-985-4141
Mailing Address - Fax:801-985-4242
Practice Address - Street 1:4949 S 900 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3777
Practice Address - Country:US
Practice Address - Phone:801-621-0480
Practice Address - Fax:801-612-3485
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1130289934152W00000X
UT1130288904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1737499OtherFIRST HEALTH NETWORK
UT589803OtherDMBA
UT11445324OtherCAQH
UT81820OtherPEHP
UTU06077Medicare UPIN
UTP00177506Medicare ID - Type UnspecifiedRAILROAD MEDICARE