Provider Demographics
NPI:1205177417
Name:GIBBONS, LARRY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:GIBBONS
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 1:12330 PRESTON ROAD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-341-3200
Mailing Address - Fax:972-341-3225
Practice Address - Street 1:12330 PRESTON ROAD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-341-3200
Practice Address - Fax:972-341-3225
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3283207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine