Provider Demographics
NPI:1649388596
Name:GIBSON, MARIA V (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:V
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 1:5916 E MCKELLIPS RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2755
Mailing Address - Country:US
Mailing Address - Phone:480-930-4477
Mailing Address - Fax:
Practice Address - Street 1:5916 E MCKELLIPS RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2755
Practice Address - Country:US
Practice Address - Phone:480-930-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53596207Q00000X
SC23088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC230887Medicaid
SCAA7223G105Medicare UPIN
H619744157Medicare Oscar/Certification
SC230887Medicaid