Provider Demographics
NPI:1952477929
Name:GIBSON, DANIEL PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PETER
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 1:13345 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3318
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST STE 250
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-381-9384
Practice Address - Fax:208-381-9385
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI653102085N0700X, 2085R0202X, 2085R0204X
IDM-173592085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-17359Medicaid
TNQ006012Medicaid