Provider Demographics
NPI:1316930704
Name:GIBSON, ROGER O (M D)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:O
Last Name:GIBSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 GERMANTOWN BEND CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7238
Mailing Address - Country:US
Mailing Address - Phone:901-751-0150
Mailing Address - Fax:901-695-2007
Practice Address - Street 1:295 GERMANTOWN BEND CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7238
Practice Address - Country:US
Practice Address - Phone:901-751-0150
Practice Address - Fax:901-695-2007
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382574Medicaid
TN2006851OtherBLUE CROSS OF TENNESSEE
TN10277OtherTN MEDICAL LICENSE
TN44D0314829OtherCLIA
TN44D0314829OtherCLIA
TN3170505Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER