Healthcare Provider Details

I. General information

NPI: 1336889252
Provider Name (Legal Business Name): JONATHAN GIBBONS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 STONELEIGH AVE
CARMEL NY
10512-3997
US

IV. Provider business mailing address

670 STONELEIGH AVE BUILDING 664, SUITE 301
CARMEL NY
10512-2450
US

V. Phone/Fax

Practice location:
  • Phone: 845-279-5711
  • Fax:
Mailing address:
  • Phone: 845-279-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: