Provider Demographics
NPI:1639284649
Name:GIBSON, JAMES J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:GIBSON
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:#420
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54308-8900
Practice Address - Country:US
Practice Address - Phone:920-288-8400
Practice Address - Fax:920-288-8461
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37129207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32524500Medicaid
BG4743565OtherDEA NUMBER
WI32524500Medicaid