Provider Demographics
NPI:1821578790
Name:GIPSON, TAMALA
Entity Type:Individual
Prefix:
First Name:TAMALA
Middle Name:
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAPLE PL
Mailing Address - Street 2:
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-3818
Mailing Address - Country:US
Mailing Address - Phone:903-952-8447
Mailing Address - Fax:
Practice Address - Street 1:508 PIERCE ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-3335
Practice Address - Country:US
Practice Address - Phone:903-881-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213942208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation