Basic Information
| Provider Information | |||||||||
| NPI: | 1194745885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | RAYMOND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 LA CALMA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787523825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124528533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6300 LA CALMA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787523825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124528533 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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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 | 204D00000X | 02003009A | IN | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207P00000X | 005432 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P8586 | 01 | TX | TEXAS MEDICAL BOARD | OTHER | 005432 | 01 | AZ | MEDICAL LICENSE | OTHER |