Provider Demographics
NPI:1053824649
Name:GIBSON, ANDREW R (IDC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02841-1006
Mailing Address - Country:US
Mailing Address - Phone:401-841-6737
Mailing Address - Fax:
Practice Address - Street 1:43 SMITH ROAD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02841
Practice Address - Country:US
Practice Address - Phone:401-841-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Single Specialty