Provider Demographics
NPI:1528031101
Name:GIBSON, WARREN DOUGLAS
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:DOUGLAS
Last Name:GIBSON
Suffix:
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 1:1629 HIGHWAY 544
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8452
Mailing Address - Country:US
Mailing Address - Phone:843-347-7281
Mailing Address - Fax:843-347-9785
Practice Address - Street 1:1629 HIGHWAY 544
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8452
Practice Address - Country:US
Practice Address - Phone:843-347-7281
Practice Address - Fax:843-347-9785
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2045Medicaid
4428040001Medicare NSC