MEDICARE: DR. LEE L GIBSON D.O.

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	207P00000X	Emergency Medicine Physician	OS5067	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780608778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEE L GIBSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 118
Second Line	:
City	:	FORT WHITE
State	:	FL
Zip	:	32038-0118
Country	:	US
Telephone Number	:	386-497-1240
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 SW NATURES CT
Second Line	:
City	:	FORT WHITE
State	:	FL
Zip	:	32038-2357
Country	:	US
Telephone Number	:	386-961-4728
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/14/2008

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