Provider Demographics
NPI:1508185554
Name:GIBSON, JERRY P (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:P
Last Name:GIBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216E GRANTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1396
Mailing Address - Country:US
Mailing Address - Phone:319-270-9454
Mailing Address - Fax:
Practice Address - Street 1:3140 WHITE OAK CR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IA
Practice Address - Zip Code:52327
Practice Address - Country:US
Practice Address - Phone:319-648-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist