Provider Demographics
NPI:1033507348
Name:GIBSON, MYRA C (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 VAN DYKE RD # 193
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8025
Mailing Address - Country:US
Mailing Address - Phone:813-482-5291
Mailing Address - Fax:
Practice Address - Street 1:4123 HIGHLAND PARK CIR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5314
Practice Address - Country:US
Practice Address - Phone:813-482-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0060279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine