Provider Demographics
NPI:1639239312
Name:GIBBONS, PETER DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DOUGLAS
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BELMONT AVE.
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-257-8360
Mailing Address - Fax:802-257-8849
Practice Address - Street 1:17 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-257-0115
Practice Address - Fax:802-257-8849
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00041802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00004779OtherBLUE SHIELD
VT03-0239725OtherCOMMERCIAL
VT0004779Medicaid
VTB85606Medicare UPIN
VTGIVT4779Medicare ID - Type Unspecified