Provider Demographics
NPI:1992319719
Name:GIBSON, KAITLYN RENAE (OD)
Entity type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:RENAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13115 WICKER AVE STE E
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-7400
Mailing Address - Country:US
Mailing Address - Phone:219-374-7800
Mailing Address - Fax:219-374-5196
Practice Address - Street 1:13115 WICKER AVE STE E
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-7400
Practice Address - Country:US
Practice Address - Phone:219-374-7800
Practice Address - Fax:219-374-5196
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004243A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist