Provider Demographics
NPI:1639193477
Name:GIBSON, RANDALL W (MED, LMT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MED, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2567 ABINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4037
Mailing Address - Country:US
Mailing Address - Phone:330-701-8780
Mailing Address - Fax:
Practice Address - Street 1:3250 W MARKET ST
Practice Address - Street 2:SUITE #104
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3336
Practice Address - Country:US
Practice Address - Phone:330-701-8780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33-00-4126225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist