Provider Demographics
NPI:1821097486
Name:GIBSON, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-2705
Mailing Address - Country:US
Mailing Address - Phone:330-637-0356
Mailing Address - Fax:330-637-0361
Practice Address - Street 1:310 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-2705
Practice Address - Country:US
Practice Address - Phone:330-637-0356
Practice Address - Fax:330-637-0361
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-01-06
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
OH35048883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4122159OtherAETNA
OH000000147036OtherANTHEM
OH0631865Medicaid
OH4122159OtherAETNA
OHA80620Medicare UPIN