Provider Demographics
NPI:1497801609
Name:GIBSON, WILLIE B (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:B
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:18300 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-4162
Mailing Address - Country:US
Mailing Address - Phone:313-535-9366
Mailing Address - Fax:313-534-1970
Practice Address - Street 1:18300 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4162
Practice Address - Country:US
Practice Address - Phone:313-535-9366
Practice Address - Fax:313-534-1970
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2009-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035487207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1098127Medicaid
MIA74504Medicare UPIN
MI0823880Medicare ID - Type Unspecified