Healthcare Provider Details

I. General information

NPI: 1093125676
Provider Name (Legal Business Name): STEPHEN GIBBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 09/14/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4689 HIGHWAY 17 SUITE 11
FLEMING ISLAND FL
32003
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 904-375-9753
  • Fax: 904-375-8380
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2019-01449
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME145626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: