Provider Demographics
NPI:1093775017
Name:GIBBIN, CANDACE L (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:L
Last Name:GIBBIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9063
Mailing Address - Country:US
Mailing Address - Phone:214-456-6333
Mailing Address - Fax:214-456-6154
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9063
Practice Address - Country:US
Practice Address - Phone:214-456-6333
Practice Address - Fax:214-456-6154
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071808L2080P0202X
TXN36692080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018146860012Medicaid
PAMD071808LOtherMEDICAL LICENSE NUMBER
TXN3669OtherMEDICAL LICENSE NUMBER
PA0018146860013Medicaid
PA0018146860012Medicaid
PA0018146860013Medicaid