Basic Information
| Provider Information | |||||||||
| NPI: | 1619357209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 LOUISIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128951 | ||||||||
| FaxNumber: | 3182126752 | ||||||||
| Practice Location | |||||||||
| Address1: | 8001 YOUREE DR STE 4007 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123821 | ||||||||
| FaxNumber: | 3182123825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 311424 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | R9490 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.