Provider Demographics
NPI:1003876798
Name:GIBSON, JEREMY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:L
Last Name:GIBSON
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4150 CROSSPOINT BLVD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1803
Practice Address - Country:US
Practice Address - Phone:956-296-1960
Practice Address - Fax:956-296-2855
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370019198OtherRR/MEDICARE
TX1446577-01Medicaid
TX1446577-02OtherCSHCN
TX8B4705OtherBLUE SHIELD