Provider Demographics
NPI:1447245030
Name:GIBSON, DOUGLAS W (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:RADIOLOGY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2803
Practice Address - Country:US
Practice Address - Phone:860-679-2784
Practice Address - Fax:860-679-4126
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0170992085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400027972Medicare PIN
B38044Medicare UPIN