Provider Demographics
NPI:1205879202
Name:GIBSON, XUNDA A (MD)
Entity type:Individual
Prefix:
First Name:XUNDA
Middle Name:A
Last Name:GIBSON
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 1:2436 N FEDERAL HWY STE 229
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6854
Mailing Address - Country:US
Mailing Address - Phone:561-543-0616
Mailing Address - Fax:
Practice Address - Street 1:17940 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3505
Practice Address - Country:US
Practice Address - Phone:305-621-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89553207R00000X
VI2771207R00000X
CAA83389207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270783700Medicaid
FL270783703Medicaid
FL35070OtherBCBS
P00322676OtherRR MCR
FLI20461Medicare UPIN
FLU3733BMedicare PIN
FLU3733BMedicare PIN