=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043299977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DON J. GIBSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2006
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 GRIFFIN AVE
-----------------------------------------------------
City | PORT ST JOE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32456-7748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-356-3096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 GRIFFIN AVE
-----------------------------------------------------
City | PORT ST JOE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32456-7748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-356-3096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | ME155020
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------