Provider Demographics
NPI:1972587004
Name:GIBBONS, GEORGE (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GIBBONS
Suffix:
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:10500 UNIVERSITY CENTER DR
Practice Address - Street 2:STE 175
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6494
Practice Address - Country:US
Practice Address - Phone:800-929-6694
Practice Address - Fax:407-856-2312
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94720207ZD0900X
DEC1-0007055207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274275600Medicaid
H25180Medicare UPIN
FL274275600Medicaid
FLU6580ZMedicare PIN