Provider Demographics
NPI:1780608778
Name:GIBSON, LEE L (DO)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DO
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 118
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-0118
Mailing Address - Country:US
Mailing Address - Phone:386-497-1240
Mailing Address - Fax:
Practice Address - Street 1:190 SW NATURES CT
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-2357
Practice Address - Country:US
Practice Address - Phone:386-961-4728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5067207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35654900Medicaid
E73714Medicare UPIN
FL82850Medicare ID - Type Unspecified