Provider Demographics
NPI:1972673432
Name:GIBSON, CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 ZERO ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-8663
Mailing Address - Country:US
Mailing Address - Phone:479-649-5900
Mailing Address - Fax:479-649-6724
Practice Address - Street 1:2425 ZERO ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-8663
Practice Address - Country:US
Practice Address - Phone:479-649-5900
Practice Address - Fax:479-649-6724
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2069152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
47859OtherARKANSAS BCBS
07225OtherSPECTERA
26766OtherMEDICAL EYE SERVICES
56908OtherSUPERIOR VISION PLAN
923045OtherBLOCK VISION
38855OtherAVESIS
041012OtherNATIONAL VISION ASSOCIATI
1454016OtherOPTICHOICE
47678OtherDAVIS VISION
710739595001OtherOKLAHOMA BCBS
47859OtherARKANSAS BCBS