Basic Information
Provider Information | |||||||||
NPI: | 1083694905 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GIBBS | ||||||||
FirstName: | MARTI | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | MARTI | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 658 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305030658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707181122 | ||||||||
FaxNumber: | 7705357445 | ||||||||
Practice Location | |||||||||
Address1: | 4222 FAIRBANKS DR | ||||||||
Address2: |   | ||||||||
City: | OAKWOOD | ||||||||
State: | GA | ||||||||
PostalCode: | 305662811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705346053 | ||||||||
FaxNumber: | 7705346695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2006 | ||||||||
LastUpdateDate: | 07/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 049294 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 10045228 | 01 | GA | AMERIGROUP | OTHER | 336006 | 01 | GA | WELLCARE | OTHER | 000909015A | 05 | GA |   | MEDICAID | 52862399 | 01 | GA | BCBS | OTHER | 80177932 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER | 6794635 | 01 | GA | CIGNA | OTHER | 0100985 | 01 | GA | UNITED HEALTHCARE | OTHER | 7809239 | 01 | GA | AETNA | OTHER |