Provider Demographics
NPI:1265546055
Name:GIBSON, GWENDOLYN OCTAVIA (MD)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:OCTAVIA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9900 INDEPENDENCE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1473
Mailing Address - Country:US
Mailing Address - Phone:804-747-1855
Mailing Address - Fax:804-762-8837
Practice Address - Street 1:9900 INDEPENDENCE PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1473
Practice Address - Country:US
Practice Address - Phone:804-747-1855
Practice Address - Fax:804-762-8837
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-057103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
234086OtherANTHEM - HANOVER COUNTY
VA6730043Medicaid
VA0101-057103OtherSTATE LICENSE
179099OtherANTHEM - HENRICO COUNTY
288630OtherSOUTHERN HEALTH
3325244OtherCIGNA
3325244OtherCIGNA
H08713Medicare UPIN