Provider Demographics
NPI:1801993027
Name:GIBBS, STEPHEN DELANO (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DELANO
Last Name:GIBBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SOUTHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4330
Mailing Address - Country:US
Mailing Address - Phone:814-536-7045
Mailing Address - Fax:814-539-3927
Practice Address - Street 1:572 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-349-7720
Practice Address - Fax:724-349-8993
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012603E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
030692Medicare ID - Type Unspecified
D15572Medicare UPIN