Provider Demographics
NPI:1508624016
Name:GIBSON, ANTONIO L SR
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:L
Last Name:GIBSON
Suffix:SR
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 1:594 GERONIMO DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-9375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:594 GERONIMO DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-9375
Practice Address - Country:US
Practice Address - Phone:317-413-8137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN202303151673406171WV0202X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
No172A00000XOther Service ProvidersDriver