Provider Demographics
NPI:1477558310
Name:GIBBONS, JAMES J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-386-7679
Practice Address - Street 1:615 S NEW BALLAS RD DEPT OF
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:636-386-7679
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D30207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202056826Medicaid
MO052010325Medicare PIN
MOA12832Medicare UPIN