Provider Demographics
NPI:1306990783
Name:J. DAVID GIBEAULT, MD, PC
Entity type:Organization
Organization Name:J. DAVID GIBEAULT, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GIBEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-577-1200
Mailing Address - Street 1:PO BOX 30370
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-0370
Mailing Address - Country:US
Mailing Address - Phone:520-722-0777
Mailing Address - Fax:520-290-9713
Practice Address - Street 1:3100 N CAMPBELL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2315
Practice Address - Country:US
Practice Address - Phone:520-577-1200
Practice Address - Fax:520-577-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13121207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0337040OtherBCBSAZ
AZ249202Medicaid
AZC99540Medicare UPIN
AZAZ0337040OtherBCBSAZ