Provider Demographics
NPI:1700904406
Name:GIBSON, ROBERT RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDALL
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0470
Mailing Address - Country:US
Mailing Address - Phone:907-442-7148
Mailing Address - Fax:
Practice Address - Street 1:212 CARLANNA LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5642
Practice Address - Country:US
Practice Address - Phone:907-228-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5493207Q00000X
CAA51581207Q00000X
CO29061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3965Medicaid
AKU56146Medicare UPIN
AK8EB631Medicare PIN