Provider Demographics
NPI:1114037306
Name:GIBSON, DAVID BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BENJAMIN
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 1:6029 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-726-1056
Mailing Address - Fax:901-726-5867
Practice Address - Street 1:2996 KATE BOND RD
Practice Address - Street 2:SUITE 309
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4030
Practice Address - Country:US
Practice Address - Phone:901-726-1056
Practice Address - Fax:901-726-5867
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40059208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3334090Medicaid
TNP00322634OtherRAILROAD MEDICARE
TN3334090Medicare ID - Type Unspecified
TNA63712Medicare UPIN