Provider Demographics
NPI:1518501667
Name:GIBBON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GIBBON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 DUNFORD DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2319
Mailing Address - Country:US
Mailing Address - Phone:847-772-8794
Mailing Address - Fax:
Practice Address - Street 1:432 DUNFORD DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2319
Practice Address - Country:US
Practice Address - Phone:847-772-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer