Provider Demographics
NPI:1336161421
Name:GIBBONS, MELINDA AILEEN (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:AILEEN
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:AILEEN
Other - Last Name:MAGGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14445 OLIVE VIEW DR
Mailing Address - Street 2:DEPT SURGERY OLIVE VIEW- UCLA MEDICAL CTR 6D
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342
Mailing Address - Country:US
Mailing Address - Phone:818-364-3194
Mailing Address - Fax:818-364-3514
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:DEPT SURGERY OLIVE VIEW- UCLA MEDICAL CTR 6D
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:818-364-3194
Practice Address - Fax:818-364-3514
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60131208600000X
CAA060131208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A601310Medicaid
CA00A601310Medicaid
CAH35970Medicare UPIN