Provider Demographics
NPI:1871512608
Name:GIBSON, SIMON (PT)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 34TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2815
Mailing Address - Country:US
Mailing Address - Phone:510-339-2116
Mailing Address - Fax:510-339-0647
Practice Address - Street 1:473 34TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2815
Practice Address - Country:US
Practice Address - Phone:510-339-2116
Practice Address - Fax:510-339-0647
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT13625OtherBLUE SHIELD OF CA
CA0PT136250Medicare PIN