Provider Demographics
NPI:1245501378
Name:EDWARD D. GIBSON JR MD PA
Entity type:Organization
Organization Name:EDWARD D. GIBSON JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSHIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-624-9634
Mailing Address - Street 1:12241 LYNDELL PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2617
Mailing Address - Country:US
Mailing Address - Phone:850-624-9634
Mailing Address - Fax:850-769-2366
Practice Address - Street 1:1514 W 23RD ST STE A-4
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2905
Practice Address - Country:US
Practice Address - Phone:850-624-9634
Practice Address - Fax:850-769-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53278OtherBCBS OF FLORIDA
FL56431100Medicaid
FL53278OtherBCBS OF FLORIDA