Provider Demographics
NPI:1205961067
Name:GIBSON, DELORES DARLENE
Entity type:Individual
Prefix:MS
First Name:DELORES
Middle Name:DARLENE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 ARIES BROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4696
Mailing Address - Country:US
Mailing Address - Phone:614-975-8623
Mailing Address - Fax:
Practice Address - Street 1:810 BRADWELL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4160
Practice Address - Country:US
Practice Address - Phone:614-491-4141
Practice Address - Fax:614-409-2722
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2149320302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2149320OtherINDEPENDENT PROVIDER