Provider Demographics
NPI:1922324276
Name:GIBSON, MARK DUANE
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DUANE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3807
Mailing Address - Country:US
Mailing Address - Phone:423-331-4436
Mailing Address - Fax:
Practice Address - Street 1:USS LOUISVILLE
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96671-2404
Practice Address - Country:US
Practice Address - Phone:808-471-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman