Provider Demographics
NPI:1376520924
Name:GIBSON, GARY LAMAR II (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LAMAR
Last Name:GIBSON
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 749215
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9215
Mailing Address - Country:US
Mailing Address - Phone:901-226-3186
Mailing Address - Fax:
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2024-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS17040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125790Medicaid
MS00125790Medicaid
MSH58675Medicare UPIN