Provider Demographics
NPI:1821098724
Name:GIBSON, BERNARD R (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
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 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:MAIL ROUTE 783
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0783
Mailing Address - Country:US
Mailing Address - Phone:409-772-1911
Mailing Address - Fax:409-772-1943
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:MAIL ROUTE 783
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0783
Practice Address - Country:US
Practice Address - Phone:409-772-1911
Practice Address - Fax:409-772-1943
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1590174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1356822357Medicaid
TX167459001Medicaid
TX1674590-04Medicaid
TX1674590-05Medicaid
8C0160Medicare ID - Type Unspecified
TXP00235384Medicare PIN