Provider Demographics
NPI:1720181894
Name:GIBBLE, LEON WAGNER (MD)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:WAGNER
Last Name:GIBBLE
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 846
Mailing Address - Street 2:44 NORTH FIFTH STREET
Mailing Address - City:MOUNT WOLF
Mailing Address - State:PA
Mailing Address - Zip Code:17347
Mailing Address - Country:US
Mailing Address - Phone:717-266-3631
Mailing Address - Fax:717-266-6751
Practice Address - Street 1:44 NORTH FIFTH STREET
Practice Address - Street 2:
Practice Address - City:MOUNT WOLF
Practice Address - State:PA
Practice Address - Zip Code:17347
Practice Address - Country:US
Practice Address - Phone:717-266-3631
Practice Address - Fax:717-266-6751
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024778E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA194265OtherBS
PAP00314888OtherRAILROAD
PA01713101OtherBC
PA194265OtherBS