Provider Demographics
NPI:1972947943
Name:GIBSON, RENAH T (DO)
Entity Type:Individual
Prefix:
First Name:RENAH
Middle Name:T
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DO
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 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:580-233-5553
Mailing Address - Fax:580-233-5641
Practice Address - Street 1:3517 W OWEN K GARRIOTT RD STE 4
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4953
Practice Address - Country:US
Practice Address - Phone:580-233-5553
Practice Address - Fax:580-233-5641
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5563207Q00000X
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program