Healthcare Provider Details

I. General information

NPI: 1558322040
Provider Name (Legal Business Name): GARY W GIBBONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE PRESTON 2
BOSTON MA
02118-2656
US

IV. Provider business mailing address

732 HARRISON AVE PRESTON 2
BOSTON MA
02118-2656
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-6840
  • Fax: 617-414-6710
Mailing address:
  • Phone: 617-414-6840
  • Fax: 617-414-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number34791
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: