Provider Demographics
NPI:1184792178
Name:GIBBONS, EILEEN FRANCES (MD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:FRANCES
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 4TH AVE
Mailing Address - Street 2:SUITE 1240
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2573
Mailing Address - Country:US
Mailing Address - Phone:206-625-0202
Mailing Address - Fax:206-625-1910
Practice Address - Street 1:1325 4TH AVE
Practice Address - Street 2:SUITE 1240
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2573
Practice Address - Country:US
Practice Address - Phone:206-625-0202
Practice Address - Fax:206-625-1910
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA34303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1102110Medicaid
WA34303OtherMD LICENSE NUMBER
WAG58261Medicare UPIN
WA1102110Medicaid