Provider Demographics
NPI:1093876567
Name:MCGIBBON, GRACE ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ELAINE
Last Name:MCGIBBON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:5100 AUTH WAY
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-4207
Practice Address - Country:US
Practice Address - Phone:301-702-5292
Practice Address - Fax:301-702-5185
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035488207W00000X
VA0101238196207W00000X
MDD63132207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15806Medicare UPIN
017585K92Medicare ID - Type Unspecified