Provider Demographics
NPI:1750421996
Name:GIBSON, DIANE L (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
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 1:6565 FANNIN ST STE B452
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-3620
Mailing Address - Fax:713-790-2082
Practice Address - Street 1:6565 FANNIN ST STE B452
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-2677
Practice Address - Fax:713-790-2082
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133957408Medicaid
TX8AA440OtherBLUE CROSS PROVIDER ID
P00416914OtherRR MEDICARE
LA2100599Medicaid
84Y556Medicare PIN