MEDICARE: KERMIT DONALD GIBSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	02080	KY
2	261QP2300X	Primary Care Clinic/Center	02080	KY
3	208D00000X	General Practice Physician	02080	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	112617	OTHER	FED BLACK LUNG
3	1270152	OTHER	UMWA FUNDS

General Provider Information

NPI Number	:	1083760649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERMIT DONALD GIBSON DO

Provider Business Mailing Address
First Line	:	165 E MAIN ST
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-4158
Fax Number	:	606-754-5452

Provider Business Practice Location Address
First Line	:	165 E MAIN ST
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-4158
Fax Number	:	606-754-5452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	10/31/2025

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