Provider Demographics
NPI:1164427290
Name:GIBSON, MARY J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
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 1:217 SHADOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-1128
Mailing Address - Country:US
Mailing Address - Phone:423-341-6436
Mailing Address - Fax:
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-341-6436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3054016Medicaid
TN3054016Medicare PIN
TN3054016Medicaid