Provider Demographics
NPI:1427043595
Name:GIBSON, GUNNAR H (MD)
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:H
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 1:4200 N RODNEY PARHAM RD STE 202
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2460
Mailing Address - Country:US
Mailing Address - Phone:501-227-4323
Mailing Address - Fax:501-227-4149
Practice Address - Street 1:4200 N RODNEY PARHAM RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-2461
Practice Address - Country:US
Practice Address - Phone:501-227-4323
Practice Address - Fax:501-227-4149
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49022207N00000X
ARN6504207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112353001Medicaid
50608Medicare ID - Type Unspecified
AR112353001Medicaid