Provider Demographics
NPI:1518095462
Name:GIBERSON, THOMAS PAUL (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:GIBERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 RIVER BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1986
Mailing Address - Country:US
Mailing Address - Phone:678-442-3317
Mailing Address - Fax:678-442-4416
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7694
Practice Address - Country:US
Practice Address - Phone:678-442-3317
Practice Address - Fax:678-442-4416
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033090207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00429789BMedicaid
GA89BDDLNMedicare ID - Type Unspecified
GAF44433Medicare UPIN