Healthcare Provider Details

I. General information

NPI: 1447246640
Provider Name (Legal Business Name): MICHAEL SPENCER GIBSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FAIRMOUNT AVE STE 120
SAN DIEGO CA
92105-1608
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-269-1299
  • Fax: 619-961-0812
Mailing address:
  • Phone: 619-997-4859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberD54010
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC54766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: