Provider Demographics
NPI:1336256528
Name:GIBSON, JOHN H (DOM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2001 E LOHMAN AVE
Mailing Address - Street 2:110-346
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3167
Mailing Address - Country:US
Mailing Address - Phone:505-202-1625
Mailing Address - Fax:
Practice Address - Street 1:339 N ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2543
Practice Address - Country:US
Practice Address - Phone:505-202-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM890171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00RE93OtherBLUE CROSS BLUE SHIELD