Provider Demographics
NPI:1992771190
Name:GIBBON, ROBERT JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GIBBON
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 1:92 W. SUMMIT ST.
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750
Mailing Address - Country:US
Mailing Address - Phone:716-485-3690
Mailing Address - Fax:
Practice Address - Street 1:92 W. SUMMIT ST.
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750
Practice Address - Country:US
Practice Address - Phone:716-485-3690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1974192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC27643Medicare UPIN
NY56122FMedicare ID - Type UnspecifiedMEDICARE NUMBER