Provider Demographics
NPI:1336163567
Name:GIPSON, AMOS (MD)
Entity Type:Individual
Prefix:
First Name:AMOS
Middle Name:
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A.
Other - Middle Name:CARVEL
Other - Last Name:GIPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29537OtherBLUE CROSS BLUE SHIELD
FL260445100Medicaid
FL29537OtherBLUE CROSS BLUE SHIELD
FL29537ZMedicare PIN
FLD62075Medicare UPIN