Provider Demographics
NPI:1922434380
Name:GIBSON, MARK S (CSFA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 BLIND POND AVE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-5580
Mailing Address - Country:US
Mailing Address - Phone:813-892-0226
Mailing Address - Fax:
Practice Address - Street 1:2104 BLIND POND AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-5580
Practice Address - Country:US
Practice Address - Phone:813-892-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL82150246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant