Healthcare Provider Details

I. General information

NPI: 1801072756
Provider Name (Legal Business Name): GREGORY A GIBSON M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD STE 322
SAINT AUGUSTINE FL
32086-5771
US

IV. Provider business mailing address

301 HEALTH PARK BLVD STE 322
SAINT AUGUSTINE FL
32086-5771
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: CINDY GIBSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 904-824-3777