Provider Demographics
NPI:1144464454
Name:MATARRESE MCGIBBON, LIA R (DO)
Entity type:Individual
Prefix:DR
First Name:LIA
Middle Name:R
Last Name:MATARRESE MCGIBBON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LIA
Other - Middle Name:
Other - Last Name:MCGIBBON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:719-463-5600
Mailing Address - Fax:
Practice Address - Street 1:1910 COALTON RD
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-4674
Practice Address - Country:US
Practice Address - Phone:720-494-4700
Practice Address - Fax:720-494-4706
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279671207RR0500X
CO50866207RR0500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70976287Medicaid