Provider Demographics
NPI:1740322684
Name:GIBSON, TODD L (DAOM, LAC)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5577 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4119
Mailing Address - Country:US
Mailing Address - Phone:323-868-7338
Mailing Address - Fax:
Practice Address - Street 1:5577 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:CA
Practice Address - Zip Code:90042-4119
Practice Address - Country:US
Practice Address - Phone:323-868-7338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6110171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC6110OtherLICENSED ACUPUNCTURIST