Provider Demographics
NPI:1124097381
Name:GIBBONS, KEVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7923 E QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:SUITE B4
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-218-1000
Practice Address - Fax:716-650-2691
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177872207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010063202OtherUNIVERA INSURANCE
NY01432113Medicaid
NY000524440002OtherBLUE CROSS OF WNY
NYCNS177872OtherWORKERS COMPENSATION
NY0605580OtherINDEPENDENT HEALTH INS
NYCNS177872OtherWORKERS COMPENSATION
NYDD1421Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE