Provider Demographics
NPI:1326057928
Name:GIBSON, JOHN HEYL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HEYL
Last Name:GIBSON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-2200
Mailing Address - Fax:336-277-2210
Practice Address - Street 1:190 KIMEL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-277-2200
Practice Address - Fax:336-277-2210
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC364452084H0002X, 2084N0400X
NC2006-001362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00605571OtherRR MEDICARE
NCP00605571OtherRR MEDICARE