Provider Demographics
NPI:1245215979
Name:GIBERSON, FREDERICK A (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
Last Name:GIBERSON
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:PO BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4735 OGLETOWN STANTON RD
Practice Address - Street 2:MEDICAL ARTS PAVILION 2, SUITE 3301
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2072
Practice Address - Country:US
Practice Address - Phone:302-623-4370
Practice Address - Fax:302-623-4375
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC100049052086S0102X
DEC1-0004905208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE900532C63Medicare PIN
DEG47971Medicare UPIN