Provider Demographics
NPI:1093830549
Name:GIBSON, LARRY ELISHA (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ELISHA
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 NORTHSIDE DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2588
Mailing Address - Country:US
Mailing Address - Phone:478-477-4415
Mailing Address - Fax:
Practice Address - Street 1:3333 NORTHSIDE DR
Practice Address - Street 2:SUITE G
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2588
Practice Address - Country:US
Practice Address - Phone:478-477-4415
Practice Address - Fax:478-477-4419
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001656111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I354140OtherMEDICARE PTAN