Provider Demographics
NPI:1619988466
Name:GIBSON, GARY MAX (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MAX
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 1:1441 REDBUD BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-3234
Mailing Address - Country:US
Mailing Address - Phone:972-542-3364
Mailing Address - Fax:972-562-9506
Practice Address - Street 1:1441 REDBUD BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-3234
Practice Address - Country:US
Practice Address - Phone:972-542-3364
Practice Address - Fax:972-562-9506
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DD348OtherBCBSTX
TX100092903Medicaid
TX100092902Medicaid
TXP01097304Medicare UPIN
TX005424Medicare ID - Type Unspecified
TX100092902Medicaid
C16080Medicare UPIN