Organization
DRG MEDICAL LLC
Active
Other names
Gibson Family Practice
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WILLIAM LEE GIBSON JR. MD (MANAGER)
(318) 918-0058
Entity
Organization
Contact information
Practice address
1549 ELIZABETH AVE, SHREVEPORT, LA 71101-4501
(318) 918-0058
Mailing address
1549 ELIZABETH AVE, SHREVEPORT, LA 71101-4501
(318) 918-0058
Taxonomy
Speciality
Code
Description
License number
State
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
—
—
261QP2300X
Primary Care Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1509639
—
LA
Enumeration date
12/17/2018
Last updated
10/26/2020
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