Provider Demographics
NPI:1386637007
Name:GIBSON, INGER L (OD)
Entity Type:Individual
Prefix:DR
First Name:INGER
Middle Name:L
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 1:154 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9694
Mailing Address - Country:US
Mailing Address - Phone:262-249-1000
Mailing Address - Fax:262-249-1255
Practice Address - Street 1:154 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:262-249-1000
Practice Address - Fax:262-249-1255
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38618100Medicaid
WI38618100Medicaid
4792790001Medicare NSC
000087006Medicare ID - Type Unspecified