Provider Demographics
NPI:1952815748
Name:GIBSON, LARRY HIRIAM JR
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:HIRIAM
Last Name:GIBSON
Suffix:JR
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 1:12925 NORTHWEST FWY # 137
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6303
Mailing Address - Country:US
Mailing Address - Phone:346-254-8571
Mailing Address - Fax:
Practice Address - Street 1:12925 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-6303
Practice Address - Country:US
Practice Address - Phone:364-254-8571
Practice Address - Fax:364-254-8571
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$OtherBCBS TEXAS