Provider Demographics
NPI:1013022698
Name:GIPSON, KELVIN DEVANE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:DEVANE
Last Name:GIPSON
Suffix:
Gender:M
Credentials:DPM
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 123
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:FL
Mailing Address - Zip Code:32422-0123
Mailing Address - Country:US
Mailing Address - Phone:407-443-9784
Mailing Address - Fax:
Practice Address - Street 1:2600 HOSPITAL DR
Practice Address - Street 2:DOCTORS MEMORIAL HOSPITAL/DOCTOR'S SPECIALTY CLINC
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-4264
Practice Address - Country:US
Practice Address - Phone:850-547-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1341213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCZ576AMedicare PIN