Provider Demographics
NPI:1114013521
Name:GIBSON, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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 1:2051 HAMILL RD SUITE 302
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-877-1212
Mailing Address - Fax:423-877-6793
Practice Address - Street 1:2051 HAMILL RD
Practice Address - Street 2:STE 301 B
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-6614
Practice Address - Country:US
Practice Address - Phone:423-877-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD197472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3074845OtherBLUECROSS BLUESHIELD
TN3181502Medicaid
TN3046300Medicare PIN
TN3074845OtherBLUECROSS BLUESHIELD