Provider Demographics
NPI:1023068277
Name:GIBBS, HETTIE SUSIE (MD)
Entity type:Individual
Prefix:
First Name:HETTIE
Middle Name:SUSIE
Last Name:GIBBS
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 1:661 MADISON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3307
Mailing Address - Country:US
Mailing Address - Phone:901-527-2417
Mailing Address - Fax:901-522-9646
Practice Address - Street 1:661 MADISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3307
Practice Address - Country:US
Practice Address - Phone:901-527-2417
Practice Address - Fax:901-522-9646
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3019528Medicaid
TN3019528Medicare ID - Type Unspecified
TN3019528Medicaid