Provider Demographics
NPI:1962430181
Name:GIBSON, JERRY DEAN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DEAN
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 3945
Mailing Address - Street 2:DEPT 841
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77253-3945
Mailing Address - Country:US
Mailing Address - Phone:281-348-0426
Mailing Address - Fax:281-348-0426
Practice Address - Street 1:4000 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1202
Practice Address - Country:US
Practice Address - Phone:713-359-2000
Practice Address - Fax:713-359-1004
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3391207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82175FOtherBC/BS
TX050068684OtherRAILROAD MEDICARE
TX127968902Medicaid
TX82175FMedicare PIN
TX050068684OtherRAILROAD MEDICARE
TX82175FOtherBC/BS
C16082Medicare UPIN