Provider Demographics
NPI:1972603066
Name:GIBSON, RALPH MILTON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:MILTON
Last Name:GIBSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 PANTIGO PL
Mailing Address - Street 2:SUITE H
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-5920
Mailing Address - Country:US
Mailing Address - Phone:631-324-4700
Mailing Address - Fax:631-324-4748
Practice Address - Street 1:200 PANTIGO PL
Practice Address - Street 2:SUITE H
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-5920
Practice Address - Country:US
Practice Address - Phone:631-324-4700
Practice Address - Fax:631-324-4748
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY201346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG53178Medicare UPIN
NY25N721Medicare ID - Type Unspecified