Provider Demographics
NPI:1700857414
Name:GIBSON, MILES KENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:KENTON
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:92 JOE T. PETTEY DR.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642
Mailing Address - Country:US
Mailing Address - Phone:270-866-7066
Mailing Address - Fax:270-866-7068
Practice Address - Street 1:92 JOE T PETTY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-8543
Practice Address - Country:US
Practice Address - Phone:270-866-7066
Practice Address - Fax:270-866-7068
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64221567Medicaid
KY64221567Medicaid
KYC75022Medicare UPIN