Provider Demographics
NPI:1912987504
Name:GIBSON, JEREMY BRENDON (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BRENDON
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 1:1650 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-4717
Mailing Address - Country:US
Mailing Address - Phone:507-529-6616
Mailing Address - Fax:507-529-6622
Practice Address - Street 1:1650 4TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-4717
Practice Address - Country:US
Practice Address - Phone:507-529-6616
Practice Address - Fax:507-529-6622
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55625207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology