Provider Demographics
NPI:1548270630
Name:GIBSON, GREGORY ALAN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
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:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-3777
Mailing Address - Fax:904-824-6050
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 5008
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-824-3777
Practice Address - Fax:904-824-6050
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060293207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01087699OtherRAILROAD MEDICARE
FL12553OtherBLUE CROSS BLUE SHIELD
FLE95209Medicare UPIN
FL12553OtherBLUE CROSS BLUE SHIELD