Basic Information
| Provider Information | |||||||||
| NPI: | 1417920323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 S. UTICA AVENUE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185793826 | ||||||||
| FaxNumber: | 9185791262 | ||||||||
| Practice Location | |||||||||
| Address1: | 9245 S. MINGO | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183927500 | ||||||||
| FaxNumber: | 9182542119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 05/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 16190 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.