Provider Demographics
NPI:1467537548
Name:GIBSON, ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ROCKLAND ROAD
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND ROAD
Practice Address - Street 2:PROVIDER ENROLLMENT DEPT
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19732-0191
Practice Address - Country:US
Practice Address - Phone:302-651-6212
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127936208000000X, 2080N0001X
PAMD032476E2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1272426Medicaid
PA1117920Medicaid
NJ988804Medicaid
MD1398091Medicaid
FL017688600Medicaid
MD1398091Medicaid
FL017688600Medicaid
518979Medicare PIN