Basic Information
| Provider Information | |||||||||
| NPI: | 1083717565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 S RIDGEWOOD AVE UNIT 408 | ||||||||
| Address2: | |||||||||
| City: | SOUTH DAYTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321193505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165384729 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3033 CAMPUS DR STE W225 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009976196 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24750 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.043934 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101256861 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 072607 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2014-02167 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 37406 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 51945 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 16754 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47505 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD042677 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-10326 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME108274 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1083717565 | 01 | FL | MULTIPLAN | OTHER | 009602100 | 05 | FL | MEDICAID | 14S8Z | 01 | FL | BCBS | OTHER | 1083717565 | 01 | FL | TRICARE | OTHER | P01574249 | 01 | FL | RAILROAD | OTHER | 1083717565 | 01 | FL | VHN | OTHER |