Basic Information
| Provider Information | |||||||||
| NPI: | 1528562204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1809 NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921132113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD61072586 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 174627 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.