Healthcare Provider Details

I. General information

NPI: 1548270630
Provider Name (Legal Business Name): GREGORY ALAN GIBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD SUITE 5008
SAINT AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

PO BOX 3123
SAINT AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-3777
  • Fax: 904-824-6050
Mailing address:
  • Phone: 904-824-3777
  • Fax: 904-824-6050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME0060293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: