Provider Demographics
NPI:1124053277
Name:GIBSON, CHARLES M (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CARTER DR
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-2956
Mailing Address - Country:US
Mailing Address - Phone:617-525-6884
Mailing Address - Fax:
Practice Address - Street 1:350 LONGWOOD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5726
Practice Address - Country:US
Practice Address - Phone:617-525-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59954207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology