Provider Demographics
NPI:1609895986
Name:GIBSON, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 N ROUTE 309
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-1109
Mailing Address - Country:US
Mailing Address - Phone:484-526-7337
Mailing Address - Fax:
Practice Address - Street 1:7001 N ROUTE 309
Practice Address - Street 2:
Practice Address - City:COOPERSBURG
Practice Address - State:PA
Practice Address - Zip Code:18036-1109
Practice Address - Country:US
Practice Address - Phone:484-526-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421913208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010097973Medicaid
NJ0047333Medicaid
I18039Medicare UPIN
PA084000Medicare ID - Type Unspecified