Healthcare Provider Details

I. General information

NPI: 1720089444
Provider Name (Legal Business Name): SUSAN K GIBBONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 NEW SCOTLAND AVE DEPT RADIATION ONCOLOGY
ALBANY NY
12208-3412
US

IV. Provider business mailing address

PO BOX 8510 SUSAN K GIBBONS MD PLLC
ALBANY NY
12208-0510
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-3368
  • Fax: 518-262-3399
Mailing address:
  • Phone: 518-262-3368
  • Fax: 518-262-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number71830
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number192535
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: