Healthcare Provider Details

I. General information

NPI: 1568484293
Provider Name (Legal Business Name): GARY W. GIBBON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 SANTA MONICA BLVD STE 201
SANTA MONICA CA
90404-2306
US

IV. Provider business mailing address

2222 SANTA MONICA BLVD STE 201
SANTA MONICA CA
90404-2306
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-4090
  • Fax: 310-935-3038
Mailing address:
  • Phone: 310-453-4090
  • Fax: 310-829-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA41221
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA41221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: