Healthcare Provider Details

I. General information

NPI: 1639284649
Provider Name (Legal Business Name): JAMES J GIBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD #420
GREEN BAY WI
54308-8900
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8400
  • Fax: 920-288-8461
Mailing address:
  • Phone:
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number37129
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: