Provider Demographics
NPI:1215010020
Name:GIBBS, SEAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:L
Last Name:GIBBS
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 1:920 DOUG WHITE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4181
Mailing Address - Country:US
Mailing Address - Phone:843-848-4640
Mailing Address - Fax:843-839-2382
Practice Address - Street 1:920 DOUG WHITE DR STE 250
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4181
Practice Address - Country:US
Practice Address - Phone:843-848-4640
Practice Address - Fax:843-839-2382
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28519207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGROUPGP3744Medicaid
SCI62453Medicare UPIN
SCAA15649084Medicare PIN
SCAA15647719Medicare PIN