MEDICARE: DR. DONALD E GIBBONS III MD

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
1	207P00000X	Emergency Medicine Physician	336077005	IL
2	207P00000X	Emergency Medicine Physician	M4791	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8W0733	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	P00364135	OTHER	TX	RAILROAD

General Provider Information

NPI Number	:	1720019623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD E GIBBONS III MD

Provider Business Mailing Address
First Line	:	758 N LARRABEE ST
Second Line	:	APT. 514
City	:	CHICAGO
State	:	IL
Zip	:	60610-6445
Country	:	US
Telephone Number	:	773-710-1654
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 W MAIN ST
Second Line	:	EMERGENCY DEPARTMENT
City	:	LEWISVILLE
State	:	TX
Zip	:	75057-3629
Country	:	US
Telephone Number	:	972-420-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/10/2011

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