MEDICARE: DR. PAUL TRAVIS GIBONEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A67450	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WA67450C	OTHER		PPIN

General Provider Information

NPI Number	:	1578634234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL TRAVIS GIBONEY MD

Provider Business Mailing Address
First Line	:	3708 PONTIAC STREET
Second Line	:
City	:	LA CRESENTA
State	:	CA
Zip	:	91214-1734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 N FIGUEROA ST
Second Line	:	ROOM 531-A
City	:	LOS ANGELES
State	:	CA
Zip	:	90012-2602
Country	:	US
Telephone Number	:	213-240-8353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	03/07/2023

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