Provider Demographics
NPI:1205936796
Name:GIBSON, SAMUEL MARLIN (PT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MARLIN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT
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 247
Mailing Address - Street 2:
Mailing Address - City:GUNTER
Mailing Address - State:TX
Mailing Address - Zip Code:75058-0247
Mailing Address - Country:US
Mailing Address - Phone:903-433-1401
Mailing Address - Fax:903-433-1398
Practice Address - Street 1:610 N 8TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:GUNTER
Practice Address - State:TX
Practice Address - Zip Code:75058-3586
Practice Address - Country:US
Practice Address - Phone:903-433-1401
Practice Address - Fax:903-433-1398
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1132587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6765OtherBCBS OF TEXAS
TX8T6765OtherBCBS OF TEXAS