1497581151 NPI number — DR. KENNETH BROOKS GIBSON III OD

Table of content: DR. KENNETH BROOKS GIBSON III OD (NPI 1497581151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497581151 NPI number — DR. KENNETH BROOKS GIBSON III OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
KENNETH
Provider Middle Name:
BROOKS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
OD
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:
1497581151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6815 SATYA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37412-4295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-936-7815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
97 PARKWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT OGLETHORPE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30742-4249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
762-887-6053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2024

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: 152W00000X , with the licence number:  OPT003618 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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