Provider Demographics
NPI:1083609101
Name:GIBSON, DUANE PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:PHILLIP
Last Name:GIBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 COURT ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2156
Mailing Address - Country:US
Mailing Address - Phone:209-223-2020
Mailing Address - Fax:209-223-2046
Practice Address - Street 1:817 COURT ST
Practice Address - Street 2:SUITE 10
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2156
Practice Address - Country:US
Practice Address - Phone:209-223-2020
Practice Address - Fax:209-223-2046
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10077T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0100771Medicaid
CASD0100771Medicaid
CASD0100771Medicare PIN