Provider Demographics
NPI:1306171582
Name:GIBSON, VIENNA L (DO)
Entity type:Individual
Prefix:DR
First Name:VIENNA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:VIENNA
Other - Middle Name:M
Other - Last Name:LOWENBRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-0691
Mailing Address - Country:US
Mailing Address - Phone:843-651-4600
Mailing Address - Fax:
Practice Address - Street 1:4017 HIGHWAY 17 # 200
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5032
Practice Address - Country:US
Practice Address - Phone:843-651-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36498207N00000X
FLUO2197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC3276D652OtherMEDICARE PTAN