Provider Demographics
NPI:1578507596
Name:GIBSON, JACKSON V (MD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:V
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:910-420-1608
Practice Address - Street 1:15 REGIONAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8850
Practice Address - Country:US
Practice Address - Phone:910-255-4400
Practice Address - Fax:910-420-1608
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFH1000130OtherFIRSTCAROLINACARE PROV.#
NC8935323Medicaid
NC110081949OtherPALMETTO GBA PROVIDER#
SCQ27189OtherSC MEDICAID PROVIDER#
NC35323OtherBC/BS NC PROVIDER#
NC0401871OtherEVERCARE
NC80140OtherMEDCOST PROVIDER#
NC35323OtherBC/BS NC PROVIDER#
NC110081949OtherPALMETTO GBA PROVIDER#