Healthcare Provider Details

I. General information

NPI: 1780698811
Provider Name (Legal Business Name): JACOB B GIBSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR STE 1000
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-223-4461
  • Fax: 937-449-7603
Mailing address:
  • Phone: 937-991-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number34008573
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34-00-8573
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number34008573
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34.008573
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: