Provider Demographics
NPI:1255313912
Name:GIBSON, CAROLYN CELESTE (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:CELESTE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1906
Mailing Address - Country:US
Mailing Address - Phone:618-542-6677
Mailing Address - Fax:618-542-6688
Practice Address - Street 1:630 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1906
Practice Address - Country:US
Practice Address - Phone:618-542-6677
Practice Address - Fax:618-542-6688
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3979170002Medicare NSC
L86595Medicare PIN
U85639Medicare UPIN
3979170005Medicare NSC
L86591Medicare PIN
3979170003Medicare NSC
3979170001Medicare NSC
L86590Medicare PIN
L86593Medicare PIN
3979170004Medicare NSC
L86594Medicare PIN