Provider Demographics
NPI:1386346989
Name:GIFFORD, BARRETT (LD)
Entity type:Individual
Prefix:
First Name:BARRETT
Middle Name:
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3431
Mailing Address - Country:US
Mailing Address - Phone:406-250-4398
Mailing Address - Fax:
Practice Address - Street 1:935 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2143
Practice Address - Country:US
Practice Address - Phone:541-482-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-10227755133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered