Basic Information
| Provider Information | |||||||||
| NPI: | 1114037306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6029 WALNUT GROVE RD | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017261056 | ||||||||
| FaxNumber: | 9017265867 | ||||||||
| Practice Location | |||||||||
| Address1: | 2996 KATE BOND RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | BARTLETT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381334030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017261056 | ||||||||
| FaxNumber: | 9017265867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 40059 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3334090 | 05 | TN | MEDICAID | P00322634 | 01 | TN | RAILROAD MEDICARE | OTHER |