MEDICARE: DR. JACOB B 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	207R00000X	Internal Medicine Physician	34-00-8573	OH
2	207RC0000X	Cardiovascular Disease Physician	34.008573	OH
3	207UN0901X	Nuclear Cardiology Physician	34008573	OH
4	207RI0011X	Interventional Cardiology Physician	34008573	OH

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	:	1780698811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB B GIBSON DO

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3188
Fax Number	:	937-223-9811

Provider Business Practice Location Address
First Line	:	2350 MIAMI VALLEY DR STE 310
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4778
Country	:	US
Telephone Number	:	937-438-5216
Fax Number	:	937-438-5229

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	03/22/2022

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Directions to “ DR. JACOB B GIBSON DO” Practice Location

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