Provider Demographics
NPI:1225486053
Name:GIBSON, DUSTIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 CENTRAL PARKE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6852
Mailing Address - Country:US
Mailing Address - Phone:513-701-6100
Mailing Address - Fax:
Practice Address - Street 1:11003 MONTGOMERY RD
Practice Address - Street 2:A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2306
Practice Address - Country:US
Practice Address - Phone:513-469-1444
Practice Address - Fax:513-247-9484
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-016362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366632Medicare PIN