Healthcare Provider Details

I. General information

NPI: 1164421442
Provider Name (Legal Business Name): CAROL ANN JACKSON-GIBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 YOUNGS RD SUITE 111
WILLIAMSVILLE NY
14221-8053
US

IV. Provider business mailing address

1150 YOUNGS RD SUITE 111
WILLIAMSVILLE NY
14221-8053
US

V. Phone/Fax

Practice location:
  • Phone: 716-688-7622
  • Fax: 716-688-7592
Mailing address:
  • Phone: 716-688-7622
  • Fax: 716-688-7592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number176786
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number176786
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: