Healthcare Provider Details

I. General information

NPI: 1962474965
Provider Name (Legal Business Name): JOAN E GIBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 01/18/2008

III. Provider practice location address

1 HIGHWAY 18
PINE RIDGE SD
57770-9998
US

IV. Provider business mailing address

PO BOX 1201 HIGHWAY 18 EAST
PINE RIDGE SD
57770-1201
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-5131
  • Fax: 605-867-3306
Mailing address:
  • Phone: 605-867-5131
  • Fax: 605-867-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5548
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33818
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number217566
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: