Provider Demographics
NPI:1497349435
Name:GIBSON, MICHAEL ERIC
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 NAPA DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7954
Mailing Address - Country:US
Mailing Address - Phone:404-423-1133
Mailing Address - Fax:
Practice Address - Street 1:3899 NAPA DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7954
Practice Address - Country:US
Practice Address - Phone:404-423-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor