Provider Demographics
NPI:1669912598
Name:GIBSON, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 DORCHESTER DR
Mailing Address - Street 2:17
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-4561
Mailing Address - Country:US
Mailing Address - Phone:580-419-4488
Mailing Address - Fax:
Practice Address - Street 1:2810 DORCHESTER DR
Practice Address - Street 2:17
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-4561
Practice Address - Country:US
Practice Address - Phone:580-419-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2084P0800X103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid