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NPI Code Detail

MEDICARE: GWENDOLYN LOUISE GIBSON M.D.

MEDICARE: GWENDOLYN LOUISE GIBSON M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician16190OK

General Provider Information

NPI Number : 1417920323
Entity Type Code : Individual
Provider Name (Legal Business Name) : GWENDOLYN LOUISE GIBSON M.D.
Provider Business Mailing Address
First Line : 1145 S. UTICA AVENUE
Second Line : SUITE 110
City : TULSA
State : OK
Zip : 74104-4013
Country : US
Telephone Number : 918-579-3826
Fax Number : 918-579-1262
Provider Business Practice Location Address
First Line : 9245 S. MINGO
Second Line :
City : TULSA
State : OK
Zip : 74133-5793
Country : US
Telephone Number : 918-392-7500
Fax Number : 918-254-2119
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/10/2006
Last Update Date : 05/15/2009

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