Provider Demographics
NPI:1134416787
Name:GIBBONS, TIMOTHY SCOTT (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-1361
Mailing Address - Fax:208-467-9008
Practice Address - Street 1:310 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-1361
Practice Address - Fax:208-467-9008
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2999152W00000X
NV727152W00000X
IDODP-100526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist