Provider Demographics
NPI:1033599840
Name:GIBSON, JULIET
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIET
Other - Middle Name:
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:8144 WALNUT HILL LN STE 1300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4365
Practice Address - Country:US
Practice Address - Phone:214-420-7070
Practice Address - Fax:214-420-7380
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9065207N00000X
MA264186390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program