Provider Demographics
NPI:1861536575
Name:GIBSON, JAMES M (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7399
Mailing Address - Street 2:PMB 195
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-7399
Mailing Address - Country:US
Mailing Address - Phone:970-547-3593
Mailing Address - Fax:
Practice Address - Street 1:1020 15TH ST
Practice Address - Street 2:UNIT 26-A
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-2300
Practice Address - Country:US
Practice Address - Phone:970-547-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01285543Medicaid
CO01285543Medicaid
COCK10032Medicare PIN