Provider Demographics
NPI:1922118314
Name:GIBBONS, ALFRED EARL JR (M D)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:EARL
Last Name:GIBBONS
Suffix:JR
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 PINE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3247
Mailing Address - Country:US
Mailing Address - Phone:254-756-7044
Mailing Address - Fax:254-756-3779
Practice Address - Street 1:3115 PINE AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3247
Practice Address - Country:US
Practice Address - Phone:254-756-7044
Practice Address - Fax:254-756-3779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4846174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T591OtherBLUE CROSS/BLUE SHIELD
TX00T591Medicare ID - Type Unspecified
TXB22962Medicare UPIN