Provider Demographics
NPI:1780698811
Name:GIBSON, JACOB B (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:B
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3170 KETTERING BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2350 MIAMI VALLEY DR STE 310
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4778
Practice Address - Country:US
Practice Address - Phone:937-438-5216
Practice Address - Fax:937-438-5229
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-8573207R00000X
OH34.008573207RC0000X
OH34008573207UN0901X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2598836Medicaid
OH4173619Medicare PIN
OH2598836Medicaid