Provider Demographics
NPI:1922296458
Name:GIBSON, BRADFORD W (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:W
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 1:1200 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7659
Mailing Address - Country:US
Mailing Address - Phone:770-844-3200
Mailing Address - Fax:404-851-6325
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3200
Practice Address - Fax:404-851-6325
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1182207R00000X
GA061433208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA725131782AMedicaid
KY7100026740Medicaid
KY3385740Medicare PIN
GA511I110652Medicare PIN