Provider Demographics
NPI:1639467442
Name:GORDON L. GIBSON, M. D., P. A.
Entity Type:Organization
Organization Name:GORDON L. GIBSON, M. D., P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCNEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-227-7499
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-1190
Mailing Address - Country:US
Mailing Address - Phone:501-227-7499
Mailing Address - Fax:501-504-2404
Practice Address - Street 1:106 RIDGEWAY
Practice Address - Street 2:SUITES A & B
Practice Address - City:HOT SPRINGS,
Practice Address - State:AR
Practice Address - Zip Code:71901-7157
Practice Address - Country:US
Practice Address - Phone:501-321-0547
Practice Address - Fax:501-321-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC44842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104488001Medicaid
AR104488001Medicaid