MEDICARE: WESLEY C GIBSON LDO

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	156FX1800X	Optician	DO 4476	FL

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
2	DO 4476	OTHER	FL	OPTICIANRY LICENSE

General Provider Information

NPI Number	:	1386782183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY C GIBSON LDO

Provider Business Mailing Address
First Line	:	7720 US HIGHWAY 98 W
Second Line	:	SUITE 380
City	:	DESTIN
State	:	FL
Zip	:	32550-7230
Country	:	US
Telephone Number	:	850-862-4001
Fax Number	:	850-862-1612

Provider Business Practice Location Address
First Line	:	7720 US HIGHWAY 98 W
Second Line	:	SUITE 380
City	:	DESTIN
State	:	FL
Zip	:	32550-7230
Country	:	US
Telephone Number	:	850-862-4001
Fax Number	:	850-862-1612

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

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	08/03/2010

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Directions to “ WESLEY C GIBSON LDO” Practice Location

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