Provider Demographics
NPI:1710968532
Name:GIBSON, LAURENCE F (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:F
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 1:1 S GREENLEAF ST
Mailing Address - Street 2:STE A
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3370
Mailing Address - Country:US
Mailing Address - Phone:847-856-2525
Mailing Address - Fax:847-856-1969
Practice Address - Street 1:1 S GREENLEAF ST
Practice Address - Street 2:STE A
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3370
Practice Address - Country:US
Practice Address - Phone:847-856-2525
Practice Address - Fax:847-856-1969
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101520208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101520Medicaid
394760Medicare ID - Type Unspecified
K11666Medicare UPIN