Provider Demographics
NPI:1891808044
Name:TIMOTHY W GIBSON M D INC
Entity Type:Organization
Organization Name:TIMOTHY W GIBSON M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-848-1911
Mailing Address - Street 1:17742 BEACH BLVD STE 245
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6835
Mailing Address - Country:US
Mailing Address - Phone:714-848-1911
Mailing Address - Fax:714-841-6761
Practice Address - Street 1:17742 BEACH BLVD STE 245
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6835
Practice Address - Country:US
Practice Address - Phone:714-848-1911
Practice Address - Fax:714-841-6761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty