Provider Demographics
NPI:1659366854
Name:GIBSON, MICHELLE J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5440 WATKINS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2034
Mailing Address - Country:US
Mailing Address - Phone:601-364-2726
Mailing Address - Fax:601-364-2731
Practice Address - Street 1:5440 WATKINS DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2034
Practice Address - Country:US
Practice Address - Phone:601-364-2726
Practice Address - Fax:601-364-2731
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS157522080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119640Medicaid
MS640947461OtherTAX ID NUMBER
MS640947461OtherTAX ID NUMBER