Provider Demographics
NPI:1700818291
Name:GIBSON, MICKEY D (DC)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1092
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-1092
Mailing Address - Country:US
Mailing Address - Phone:580-338-2464
Mailing Address - Fax:580-338-1477
Practice Address - Street 1:910 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-4021
Practice Address - Country:US
Practice Address - Phone:580-338-2464
Practice Address - Fax:580-338-1477
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK-2302111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor