Provider Demographics
NPI:1023174737
Name:GIBSON, ROBERT S (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 IVY ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:434-924-2930
Practice Address - Fax:434-982-3583
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030347207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006097120Medicaid
VAB06962Medicare UPIN
VA006097120Medicaid