Provider Demographics
NPI:1427554211
Name:GIBBONS, RYAN J (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2720
Mailing Address - Country:US
Mailing Address - Phone:970-690-4240
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.153734207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program