Provider Demographics
NPI:1316917446
Name:GIBBS, CHARLES CLARENCE (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CLARENCE
Last Name:GIBBS
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:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-0890
Mailing Address - Country:US
Mailing Address - Phone:518-891-2660
Mailing Address - Fax:518-891-2663
Practice Address - Street 1:253 COUNTY ROUTE 47
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5403
Practice Address - Country:US
Practice Address - Phone:518-891-2660
Practice Address - Fax:518-891-2663
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136590207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY136590-1OtherNYS WORKERS' COMP
NY00602433Medicaid
NY00602433Medicaid
NY39983BMedicare ID - Type Unspecified