Provider Demographics
NPI:1760464242
Name:GIBSON, TIMOTHY W (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:19582 BEACH BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2996
Mailing Address - Country:US
Mailing Address - Phone:949-715-7355
Mailing Address - Fax:
Practice Address - Street 1:17742 BEACH BLVD
Practice Address - Street 2:SUITE 245
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6818
Practice Address - Country:US
Practice Address - Phone:714-848-1911
Practice Address - Fax:714-841-6761
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG70715207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF76811Medicare UPIN
CAW17847Medicare ID - Type Unspecified