Provider Demographics
NPI:1578634234
Name:GIBONEY, PAUL TRAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:TRAVIS
Last Name:GIBONEY
Suffix:
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 1:3708 PONTIAC STREET
Mailing Address - Street 2:
Mailing Address - City:LA CRESENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 N FIGUEROA ST
Practice Address - Street 2:ROOM 531-A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2602
Practice Address - Country:US
Practice Address - Phone:213-240-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA67450COtherPPIN
WA67450COtherPPIN
G75917Medicare UPIN
BG5493197OtherDEA