Provider Demographics
NPI:1588841639
Name:GIBSON, JONATHAN SEAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SEAN
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:GLENLAKE MEDICAL OFFICE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3473
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002141207R00000X
TNMD0000045295390200000X
GA068164207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program