Provider Demographics
NPI:1104973304
Name:GIBBY, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:GIBBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W MAIN
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528
Mailing Address - Country:US
Mailing Address - Phone:254-865-2166
Mailing Address - Fax:
Practice Address - Street 1:1507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1024
Practice Address - Country:US
Practice Address - Phone:254-865-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003714900Medicaid
ID1123816Medicare ID - Type Unspecified
ID003714900Medicaid