Provider Demographics
NPI:1568484293
Name:GIBBON, GARY W (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:GIBBON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2222 SANTA MONICA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2306
Mailing Address - Country:US
Mailing Address - Phone:310-453-4090
Mailing Address - Fax:310-829-2306
Practice Address - Street 1:2222 SANTA MONICA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2306
Practice Address - Country:US
Practice Address - Phone:310-453-4090
Practice Address - Fax:310-935-3038
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA41221207RP1001X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85583Medicare UPIN
CAA41221Medicare ID - Type Unspecified