Provider Demographics
NPI:1902849623
Name:GIBSON, JESSE (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 NW CURRY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1626
Mailing Address - Country:US
Mailing Address - Phone:772-879-3469
Mailing Address - Fax:
Practice Address - Street 1:373 NW CURRY ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1626
Practice Address - Country:US
Practice Address - Phone:772-879-3469
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOC2043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19441Medicare ID - Type UnspecifiedPROVIDER