Provider Demographics
NPI:1720352909
Name:GIBSON, DANIEL KENNETH (IDC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:KENNETH
Last Name:GIBSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 INTERCOVE RD
Mailing Address - Street 2:BLDG 3813
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8932
Mailing Address - Country:US
Mailing Address - Phone:757-492-1708
Mailing Address - Fax:757-492-1716
Practice Address - Street 1:1875 INTERCOVE RD
Practice Address - Street 2:BLDG 3813
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8932
Practice Address - Country:US
Practice Address - Phone:757-492-1708
Practice Address - Fax:757-492-1716
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman