Provider Demographics
NPI:1902398845
Name:GIBBONS, JOHN CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6330 E 75TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2717
Mailing Address - Country:US
Mailing Address - Phone:317-588-7130
Mailing Address - Fax:317-813-1346
Practice Address - Street 1:6330 E 75TH ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2717
Practice Address - Country:US
Practice Address - Phone:317-588-7130
Practice Address - Fax:317-813-1346
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006812A208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300064032Medicaid