1003588427 NPI number — MIKE W GIBSON

Table of content: MIKE W GIBSON (NPI 1003588427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003588427 NPI number — MIKE W GIBSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
MIKE
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003588427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 N EBRITE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75149-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-571-9273
Provider Business Mailing Address Fax Number:
866-496-5016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 N EBRITE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75149-3453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-850-9945
Provider Business Practice Location Address Fax Number:
972-546-1872
Provider Enumeration Date:
10/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  804211277 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1326388711 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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