Provider Demographics
NPI:1154457943
Name:GIPS, GREG EVANS
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:EVANS
Last Name:GIPS
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:PO BOX 4826
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-4826
Mailing Address - Country:US
Mailing Address - Phone:361-573-0212
Mailing Address - Fax:
Practice Address - Street 1:3804 JOHN STOCKBAUER DR
Practice Address - Street 2:SUITE A
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2448
Practice Address - Country:US
Practice Address - Phone:361-573-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5387780001Medicare ID - Type UnspecifiedMEDICARE ID