Provider Demographics
NPI:1518590199
Name:GIBSON, COLLEEN (OD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 PRENDERGAST PL
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5210
Mailing Address - Country:US
Mailing Address - Phone:440-781-8105
Mailing Address - Fax:
Practice Address - Street 1:50 MCNAUGHTEN RD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2129
Practice Address - Country:US
Practice Address - Phone:614-863-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist