Healthcare Provider Details

I. General information

NPI: 1326057928
Provider Name (Legal Business Name): JOHN HEYL GIBSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/25/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 KIMEL PARK DR STE 120
WINSTON SALEM NC
27103-6946
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-277-2200
  • Fax: 336-277-2210
Mailing address:
  • Phone: 336-277-2200
  • Fax: 336-277-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084H0002X
TaxonomyHospice and Palliative Medicine (Psychiatry & Neurology) Physician
License Number36445
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number36445
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2006-00136
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: