Provider Demographics
NPI:1457632515
Name:CHARLES C. GIBSON, O.D.P.A.
Entity Type:Organization
Organization Name:CHARLES C. GIBSON, O.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:ODPA
Authorized Official - Phone:479-649-5900
Mailing Address - Street 1:2425 S. ZERO STREET
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901
Mailing Address - Country:US
Mailing Address - Phone:479-649-5900
Mailing Address - Fax:479-649-6724
Practice Address - Street 1:2425 S. ZERO STREET
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-649-5900
Practice Address - Fax:479-649-6724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2069152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty