Provider Demographics
NPI:1659317964
Name:GIBSON, DAVID EVAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EVAN
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:34515 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6761
Practice Address - Country:US
Practice Address - Phone:253-952-7971
Practice Address - Fax:253-944-7922
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023338207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0170811OtherLIWA
WA8150021Medicaid
WA0170832OtherLIWA
WAGI4108OtherBSWA
WAGI4119OtherBSWA
WA0170811OtherLIWA
WAG8150021Medicare PIN
WAGAB13812Medicare PIN
WAGI4108OtherBSWA
WA0170832OtherLIWA