Provider Demographics
NPI:1346249257
Name:GIBBONS, MARK C (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GRIFFIN AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-9101
Mailing Address - Country:US
Mailing Address - Phone:478-448-4416
Mailing Address - Fax:478-448-4423
Practice Address - Street 1:1111 GRIFFIN AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9101
Practice Address - Country:US
Practice Address - Phone:478-448-4416
Practice Address - Fax:478-448-4423
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054569208800000X
NC2008-01266208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI17508Medicare UPIN
NC2401655Medicare PIN