Provider Demographics
NPI:1336147883
Name:GIBBONS, GERALD P JR (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:P
Last Name:GIBBONS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 HIGHWAY 315 BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7125
Mailing Address - Country:US
Mailing Address - Phone:570-237-5444
Mailing Address - Fax:
Practice Address - Street 1:1620 HIGHWAY 315 BLVD STE 1
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7125
Practice Address - Country:US
Practice Address - Phone:570-237-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020226E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001188OtherFIRST PRIORITY HEALTH
PA0006032010001Medicaid
PA020338000OtherBLACK LUNG
PA12039 E222OtherGEISINGER HEALTH PALN
PA020316OtherHIGHMARK BLUE SHIELD
PA020316OtherFIRST PRIORITY LIFE INS C
PA020316KLUMedicare PIN
PAC27699Medicare UPIN
PA441112473Medicare PIN