Provider Demographics
NPI:1720194087
Name:GIBSON, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2421
Mailing Address - Country:US
Mailing Address - Phone:256-259-5313
Mailing Address - Fax:256-259-4923
Practice Address - Street 1:3840 GAULT AVE N
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-5211
Practice Address - Country:US
Practice Address - Phone:256-844-4975
Practice Address - Fax:256-844-4978
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051544790OtherBLUE CROSS BLUE SHIELD
AL051544794OtherBLUE CROSS BLUE SHIELD
AL630308067Medicaid
AL051544795OtherBLUE CROSS BLUE SHIELD
AL051544789OtherBLUE CROSS BLUE SHIELD
AL630309067Medicaid
AL051544791OtherBLUE CROSS BLUE SHIELD
AL630302067Medicaid
AL630303067Medicaid
AL051544792OtherBLUE CROSS BLUE SHIELD
AL630306067Medicaid
AL630307067Medicaid
AL630303067Medicaid