Provider Demographics
NPI:1306865951
Name:GIBBONS, KATHLEEN K (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:K
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5019 KENDALL STA NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7962
Mailing Address - Country:US
Mailing Address - Phone:770-974-4314
Mailing Address - Fax:678-421-9702
Practice Address - Street 1:6131 S NORCROSS TUCKER RD
Practice Address - Street 2:STE 700
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5536
Practice Address - Country:US
Practice Address - Phone:678-205-1959
Practice Address - Fax:678-205-2092
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA026530207Q00000X
GA26530208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000639834ZMedicaid