Healthcare Provider Details

I. General information

NPI: 1346249257
Provider Name (Legal Business Name): MARK C. GIBBONS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 GRIFFIN AVE SUITE 1A
EASTMAN GA
31023-9101
US

IV. Provider business mailing address

1111 GRIFFIN AVE SUITE 1A
EASTMAN GA
31023-9101
US

V. Phone/Fax

Practice location:
  • Phone: 478-448-4416
  • Fax: 478-448-4423
Mailing address:
  • Phone: 478-448-4416
  • Fax: 478-448-4423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number054569
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2008-01266
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: