Provider Demographics
NPI:1407053036
Name:GIBSON, VANESSA R (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:R
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 1:444 MERRICK RD STE 380
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2465
Mailing Address - Country:US
Mailing Address - Phone:516-465-1901
Mailing Address - Fax:516-255-5020
Practice Address - Street 1:444 MERRICK RD STE 380
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2465
Practice Address - Country:US
Practice Address - Phone:516-465-1901
Practice Address - Fax:516-255-5020
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39734208G00000X
NY262935-1208G00000X
NY262935208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY262935-1OtherLICENSE
KY39734OtherLICENSE