MEDICARE: DR. GARY LAMAR GIBSON II M.D.

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	17040	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376520924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LAMAR GIBSON II M.D.

Provider Business Mailing Address
First Line	:	PO BOX 749215
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-9215
Country	:	US
Telephone Number	:	901-226-3186
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 22ND AVE
Second Line	:	MEDICAL TOWERS III
City	:	MERIDIAN
State	:	MS
Zip	:	39301-3223
Country	:	US
Telephone Number	:	601-483-5322
Fax Number	:	601-581-2289

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

Provider Enumeration Date	:	12/26/2005
Last Update Date	:	10/25/2024

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