Provider Demographics
NPI:1386782183
Name:GIBSON, WESLEY C (LDO)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 US HIGHWAY 98 W
Mailing Address - Street 2:SUITE 380
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7230
Mailing Address - Country:US
Mailing Address - Phone:850-862-4001
Mailing Address - Fax:850-862-1612
Practice Address - Street 1:7720 US HIGHWAY 98 W
Practice Address - Street 2:SUITE 380
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-7230
Practice Address - Country:US
Practice Address - Phone:850-862-4001
Practice Address - Fax:850-862-1612
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 4476156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630333100Medicaid
FLDO 4476OtherOPTICIANRY LICENSE