Individual
CAROL ANN JACKSON-GIBSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1150 YOUNGS RD, SUITE 111, WILLIAMSVILLE, NY 14221-8053
(716) 688-7622
(716) 688-7592
Mailing address
1150 YOUNGS RD, SUITE 111, WILLIAMSVILLE, NY 14221-8053
(716) 688-7622
(716) 688-7592
Taxonomy
Speciality
Code
Description
License number
State
2085N0904X
Nuclear Radiology Physician
176786
NY
2085R0202X
Diagnostic Radiology Physician
Primary
176786
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00025193901
UNIVERA/EXCELLUS #
NY
01
—
000525515015
BLUE CROSS WNY #
NY
05
—
01598136
—
NY
01
—
150589FF
PREFERRED CARE-ROCHESTER
NY
01
—
300118785
RAILROAD MEDICARE #
NY
01
—
5609475
INDEPENDENT HEALTH #
NY
01
—
CR-DRA176786-2W
WORKERS COMPENSATION #
NY
Enumeration date
07/19/2005
Last updated
03/11/2013
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