Provider Demographics
NPI:1558322040
Name:GIBBONS, GARY W (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:732 HARRISON AVE
Mailing Address - Street 2:PRESTON 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2656
Mailing Address - Country:US
Mailing Address - Phone:617-414-6840
Mailing Address - Fax:617-414-6710
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:PRESTON 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2656
Practice Address - Country:US
Practice Address - Phone:617-414-6840
Practice Address - Fax:617-414-6710
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2017-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA347912086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2016621Medicaid
MA2016621Medicaid
MAB97247Medicare UPIN