Provider Demographics
NPI:1548267404
Name:GIBSON, HARRIS JR (MD)
Entity type:Individual
Prefix:
First Name:HARRIS
Middle Name:
Last Name:GIBSON
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 1:101 GEORGE P HASSETT DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3201
Mailing Address - Country:US
Mailing Address - Phone:781-391-0050
Mailing Address - Fax:781-391-1767
Practice Address - Street 1:101 GEORGE P HASSETT DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3201
Practice Address - Country:US
Practice Address - Phone:781-391-0050
Practice Address - Fax:781-391-1767
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29474208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0131571Medicaid
MA0131571Medicaid
MAM0725402Medicare PIN
MAM07254Medicare ID - Type Unspecified