Basic Information
| Provider Information | |||||||||
| NPI: | 1720019623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 758 N LARRABEE ST | ||||||||
| Address2: | APT. 514 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606106445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737101654 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750573629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724201000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 336077005 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M4791 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8W0733 | 01 | TX | BCBS | OTHER | 183312101 | 05 | TX | MEDICAID | 183312102 | 05 | TX | MEDICAID | P00364135 | 01 | TX | RAILROAD | OTHER |