Healthcare Provider Details

I. General information

NPI: 1265546055
Provider Name (Legal Business Name): GWENDOLYN OCTAVIA GIBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S MAIN ST
CHATHAM VA
24531-5436
US

IV. Provider business mailing address

705 MAIN ST
DANVILLE VA
24541-1803
US

V. Phone/Fax

Practice location:
  • Phone: 434-432-4471
  • Fax: 434-432-3555
Mailing address:
  • Phone: 434-791-3630
  • Fax: 434-791-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101-057103
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: