Provider Demographics
NPI: | 1619391802 |
---|---|
Name: | GIBSON, MARK (CPO) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARK |
Middle Name: | |
Last Name: | GIBSON |
Suffix: | |
Gender: | M |
Credentials: | CPO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3334 CAPITAL MEDICAL BLVD #400 |
Mailing Address - Street 2: | |
Mailing Address - City: | TALLAHASSEE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32308-4470 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 850-877-8174 |
Mailing Address - Fax: | 850-877-5636 |
Practice Address - Street 1: | 3334 CAPITAL MEDICAL BLVD #400 |
Practice Address - Street 2: | |
Practice Address - City: | TALLAHASSEE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32308-4470 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-877-8174 |
Practice Address - Fax: | 850-877-5636 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-02-10 |
Last Update Date: | 2014-11-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | POR276 | 224P00000X, 222Z00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 224P00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Prosthetist | |
No | 222Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 951939400 | Medicaid |