Provider Demographics
NPI:1902957905
Name:GAUGHAN, KIBIBI (MD)
Entity Type:Individual
Prefix:
First Name:KIBIBI
Middle Name:
Last Name:GAUGHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-259-7303
Mailing Address - Fax:717-279-7471
Practice Address - Street 1:101 FAIRVIEW CIR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-9581
Practice Address - Country:US
Practice Address - Phone:717-279-7303
Practice Address - Fax:717-279-7471
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226201207Q00000X
PAMD440939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6538657OtherAETNA HMO
PA1025290710001Medicaid
PA1591119OtherGATEWAY HEALTH PLAN
PA2545705OtherHIGHMARK BLUE SHIELD
PA9211298OtherAETNA
PA9211298OtherAETNA