Provider Demographics
NPI:1659585800
Name:GIBSON, MELISA GAIL (MD)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:GAIL
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 1:28 CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3104
Mailing Address - Country:US
Mailing Address - Phone:802-847-4322
Mailing Address - Fax:
Practice Address - Street 1:28 CENTRE DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-3104
Practice Address - Country:US
Practice Address - Phone:802-847-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014094Medicaid