Healthcare Provider Details

I. General information

NPI: 1164378196
Provider Name (Legal Business Name): MICHAEL GIBBONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11312 WYCOMBE PARK LN
GLENN DALE MD
20769-2029
US

IV. Provider business mailing address

8843 GREENBELT RD # 103
GREENBELT MD
20770-2451
US

V. Phone/Fax

Practice location:
  • Phone: 240-350-4490
  • Fax:
Mailing address:
  • Phone: 240-350-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberD0106199
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: