MEDICARE: TIMOTHY W GIBSON M D INC

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1891808044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY W GIBSON M D INC

Provider Business Mailing Address
First Line	:	17742 BEACH BLVD STE 245
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6835
Country	:	US
Telephone Number	:	714-848-1911
Fax Number	:	714-841-6761

Provider Business Practice Location Address
First Line	:	17742 BEACH BLVD STE 245
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6835
Country	:	US
Telephone Number	:	714-848-1911
Fax Number	:	714-841-6761

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY W GIBSON
Credential	:	M.D.
Telephone Number	:	714-848-1911

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	11/20/2012

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