Provider Demographics
NPI:1770514341
Name:GIBSON, SUSAN HOLLAND (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HOLLAND
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19810 GULF BLVD
Mailing Address - Street 2:#4
Mailing Address - City:INDIAN SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33785-2314
Mailing Address - Country:US
Mailing Address - Phone:727-593-3400
Mailing Address - Fax:727-593-2829
Practice Address - Street 1:10,000 BAY PINES BLVD
Practice Address - Street 2:DEPT OF MEDICINE
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:727-319-1054
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063597207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine