Provider Demographics
NPI:1457652190
Name:GIBSON, MIA (RD,LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 E. HWY 191
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760
Mailing Address - Country:US
Mailing Address - Phone:432-640-2128
Mailing Address - Fax:
Practice Address - Street 1:8050 E HWY 191
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8607
Practice Address - Country:US
Practice Address - Phone:432-640-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00898133V00000X
TXR663188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered