Basic Information
| Provider Information | |||||||||
| NPI: | 1306990783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J. DAVID GIBEAULT, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30370 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857510370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207220777 | ||||||||
| FaxNumber: | 5202909713 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 N CAMPBELL AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857192315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205771200 | ||||||||
| FaxNumber: | 5205771559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | GIBEAULT | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5205771200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 13121 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | AZ0337040 | 01 | AZ | BCBSAZ | OTHER | 249202 | 05 | AZ | MEDICAID |