Provider Demographics
NPI:1780799387
Name:GIBSON, SANDY YEVETTE (DO)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:YEVETTE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1913
Mailing Address - Country:US
Mailing Address - Phone:708-206-1882
Mailing Address - Fax:
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-2000
Practice Address - Fax:312-572-2669
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006661A207Q00000X
IL036-082477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00382052OtherRAILROAD MEDICARE
ILK36170Medicare PIN
ILP00382052OtherRAILROAD MEDICARE