Provider Demographics
NPI:1245241413
Name:GIBSON, KENNETH WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:GIBSON
Suffix:
Gender:M
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 751
Mailing Address - Street 2:
Mailing Address - City:HULBERT
Mailing Address - State:OK
Mailing Address - Zip Code:74441-8902
Mailing Address - Country:US
Mailing Address - Phone:918-772-3390
Mailing Address - Fax:
Practice Address - Street 1:124 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HULBERT
Practice Address - State:OK
Practice Address - Zip Code:74441-8902
Practice Address - Country:US
Practice Address - Phone:918-772-3390
Practice Address - Fax:918-772-1233
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9095207Q00000X
OK2170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine