Provider Demographics
NPI:1497581151
Name:GIBSON, KENNETH BROOKS III (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BROOKS
Last Name:GIBSON
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 SATYA WAY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412-4295
Mailing Address - Country:US
Mailing Address - Phone:706-936-7815
Mailing Address - Fax:
Practice Address - Street 1:97 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4249
Practice Address - Country:US
Practice Address - Phone:762-887-6053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist