Provider Demographics
NPI:1548333727
Name:GIBBONS, JULIETTE A (MD)
Entity type:Individual
Prefix:DR
First Name:JULIETTE
Middle Name:A
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-820-3890
Mailing Address - Fax:417-820-3567
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-3890
Practice Address - Fax:417-820-3567
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MER8P50207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203460217Medicaid
MOF35304Medicare UPIN
MO078013268Medicare PIN