Provider Demographics
NPI:1205830262
Name:GIBSON, CHARLES ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:GIBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4326
Mailing Address - Country:US
Mailing Address - Phone:281-488-7213
Mailing Address - Fax:281-488-1387
Practice Address - Street 1:555 E MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4326
Practice Address - Country:US
Practice Address - Phone:281-488-7213
Practice Address - Fax:281-480-1623
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04082TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124557301Medicaid
TX89X378Medicare PIN
TXT91171Medicare UPIN