Provider Demographics
NPI:1265488134
Name:KIPP, GREGORY T (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:KIPP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4949
Mailing Address - Country:US
Mailing Address - Phone:386-767-0068
Mailing Address - Fax:386-767-4755
Practice Address - Street 1:3820 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4949
Practice Address - Country:US
Practice Address - Phone:386-767-0068
Practice Address - Fax:386-767-4755
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84117Medicare UPIN
FL19154Medicare PIN