Provider Demographics
NPI:1649345190
Name:GIBSON, WENDY S (OD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1607
Mailing Address - Country:US
Mailing Address - Phone:270-527-0951
Mailing Address - Fax:270-527-1316
Practice Address - Street 1:1512 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1607
Practice Address - Country:US
Practice Address - Phone:270-527-0951
Practice Address - Fax:270-527-1316
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY911DT152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009116Medicaid
KY77009116Medicaid
KYT54650Medicare UPIN
KY9150801Medicare ID - Type Unspecified