Provider Demographics
NPI:1164421442
Name:JACKSON-GIBSON, CAROL ANN (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:JACKSON-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 1:1150 YOUNGS RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8053
Mailing Address - Country:US
Mailing Address - Phone:716-688-7622
Mailing Address - Fax:716-688-7592
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:SUITE 111
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-688-7622
Practice Address - Fax:716-688-7592
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1767862085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5609475OtherINDEPENDENT HEALTH #
NY01598136Medicaid
NY000525515015OtherBLUE CROSS WNY #
NY150589FFOtherPREFERRED CARE-ROCHESTER
NY300118785OtherRAILROAD MEDICARE #
NYCR-DRA176786-2WOtherWORKERS COMPENSATION #
NY00025193901OtherUNIVERA/EXCELLUS #
NY000525515015OtherBLUE CROSS WNY #
NY300118785OtherRAILROAD MEDICARE #