Provider Demographics
NPI:1861756728
Name:GIBSON, DANIEL WILLIAM (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILLIAM
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVE
Mailing Address - Street 2:POB SUITE #100
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3592
Mailing Address - Country:US
Mailing Address - Phone:309-268-3761
Mailing Address - Fax:309-268-5620
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:POB SUITE #100
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3592
Practice Address - Country:US
Practice Address - Phone:309-268-3761
Practice Address - Fax:309-268-5620
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine