Healthcare Provider Details

I. General information

NPI: 1679193056
Provider Name (Legal Business Name): MICHAEL JAMES GIBSON JUBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 W 10TH AVE
COLUMBUS OH
43210-1280
US

IV. Provider business mailing address

10651 E ST
CORPUS CHRISTI TX
78419-5130
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-5130
  • Fax:
Mailing address:
  • Phone: 361-961-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102206811
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58.034842
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58.034842
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102206811
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: