Provider Demographics
NPI:1962474965
Name:GIBSON, JOAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:F
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:PO BOX 1201
Mailing Address - Street 2:HIGHWAY 18 EAST
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-5131
Mailing Address - Fax:605-867-3306
Practice Address - Street 1:1 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-9998
Practice Address - Country:US
Practice Address - Phone:605-867-5131
Practice Address - Fax:605-867-3306
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-03-26
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-01-18
Provider Licenses
StateLicense IDTaxonomies
SD5548208000000X
AZ33818208000000X
NY217566208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H38990Medicare UPIN