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General NPI Number Information
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NPI Number | 1619357209
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Entity Type | Individual
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Provider Name | CHAD MICHAEL GIBSON MD
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Gender | Male
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Dates
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Enumeration Date | 06/09/2015
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Last Update Date | 04/17/2019
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Provider Practice Location Address
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Address Line | 8001 YOUREE DR STE 4007
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City | SHREVEPORT
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State | LA
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Zip | 71115-2302
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Country | US
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Telephone | 318-212-3821
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Fax | 318-212-3825
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Provider Business Mailing Address
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Address Line | 1202 LOUISIANA AVE
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City | SHREVEPORT
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State | LA
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Zip | 71101-3910
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Country | US
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Telephone | 318-212-8951
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Fax | 318-212-6752
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 311424
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | R9490
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License Number State | TX
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