Provider Demographics
NPI:1104004365
Name:GIBSON, LEENA CAROLINE (MD)
Entity Type:Individual
Prefix:
First Name:LEENA
Middle Name:CAROLINE
Last Name:GIBSON
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 1:8700 BEVERLY BLVD
Mailing Address - Street 2:SUITE 4311
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1804
Mailing Address - Country:US
Mailing Address - Phone:310-423-4434
Mailing Address - Fax:310-423-2114
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:SUITE 4311
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-4434
Practice Address - Fax:310-423-2114
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101342208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics