Provider Demographics
NPI:1417920323
Name:GIBSON, GWENDOLYN LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LOUISE
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 1:1145 S. UTICA AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3826
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:9245 S. MINGO
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5793
Practice Address - Country:US
Practice Address - Phone:918-392-7500
Practice Address - Fax:918-254-2119
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16190208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics