Provider Demographics
NPI:1164653390
Name:GIBSON, JOHN W (CPO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7271 WURZBACH RD STE 128
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4718
Mailing Address - Country:US
Mailing Address - Phone:210-614-5500
Mailing Address - Fax:210-614-5551
Practice Address - Street 1:7271 WURZBACH RD STE 128
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4718
Practice Address - Country:US
Practice Address - Phone:210-614-5500
Practice Address - Fax:210-614-5551
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1190222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist