Provider Demographics
NPI:1013040401
Name:GIBILISCO, PAUL A (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:GIBILISCO
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 1:72 SHEPARD RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:CT
Mailing Address - Zip Code:06058-1125
Mailing Address - Country:US
Mailing Address - Phone:860-542-5643
Mailing Address - Fax:
Practice Address - Street 1:72 SHEPARD RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:CT
Practice Address - Zip Code:06058-1125
Practice Address - Country:US
Practice Address - Phone:860-542-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023213207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD21246Medicare UPIN