Provider Demographics
NPI:1952307902
Name:GIBSON, BRUCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
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 1:718 ELIZABETH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2212
Mailing Address - Country:US
Mailing Address - Phone:361-884-2858
Mailing Address - Fax:361-879-9015
Practice Address - Street 1:718 ELIZABETH ST FL 3
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2212
Practice Address - Country:US
Practice Address - Phone:361-884-2858
Practice Address - Fax:361-879-9015
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0413174400000X
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1282691-03Medicaid
TX87282KMedicare PIN
TXB22971Medicare UPIN