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General NPI Number Information
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NPI Number | 1497581151
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Entity Type | Individual
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Provider Name | KENNETH BROOKS GIBSON III OD
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Gender | Male
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Dates
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Enumeration Date | 09/10/2024
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Last Update Date | 09/10/2024
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Provider Practice Location Address
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Address Line | 97 PARKWAY DR
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City | FORT OGLETHORPE
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State | GA
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Zip | 30742-4249
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Country | US
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Telephone | 762-887-6053
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Fax |
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Provider Business Mailing Address
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Address Line | 6815 SATYA WAY
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City | CHATTANOOGA
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State | TN
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Zip | 37412-4295
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Country | US
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Telephone | 706-936-7815
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT003618
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License Number State | GA
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