Provider Demographics
NPI:1366501249
Name:FAMILY DOC, P.C.
Entity type:Organization
Organization Name:FAMILY DOC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-591-7400
Mailing Address - Street 1:4736 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-1643
Mailing Address - Country:US
Mailing Address - Phone:719-591-7400
Mailing Address - Fax:719-591-6915
Practice Address - Street 1:4736 BARNES RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-1643
Practice Address - Country:US
Practice Address - Phone:719-591-7400
Practice Address - Fax:719-591-6915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54934770Medicaid
CO54934770Medicaid