Provider Demographics
NPI:1578077228
Name:GIBSON, FRED LLOYD IV (DC)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:LLOYD
Last Name:GIBSON
Suffix:IV
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 LAKE KATHRYN CIR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-3001
Mailing Address - Country:US
Mailing Address - Phone:407-949-7037
Mailing Address - Fax:
Practice Address - Street 1:12627 SAN JOSE BLVD STE 305
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8639
Practice Address - Country:US
Practice Address - Phone:904-683-4376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor