Provider Demographics
NPI:1073591426
Name:GIBBONS, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:4465 DARROW RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1854
Mailing Address - Country:US
Mailing Address - Phone:330-688-9501
Mailing Address - Fax:330-688-9510
Practice Address - Street 1:4465 DARROW RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1854
Practice Address - Country:US
Practice Address - Phone:330-688-9501
Practice Address - Fax:330-688-9510
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062820207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0927466Medicaid
110132419Medicare PIN
OH0927466Medicaid
0739016Medicare PIN