Provider Demographics
NPI:1053308874
Name:GIBBONS, GLENN G (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:G
Last Name:GIBBONS
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 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1480 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-3449
Practice Address - Country:US
Practice Address - Phone:479-996-5585
Practice Address - Fax:479-996-5386
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200004590AMedicaid
AR148914001Medicaid
OK200004590AMedicaid
ARH78524Medicare UPIN