Healthcare Provider Details

I. General information

NPI: 1265060230
Provider Name (Legal Business Name): KIPSON CHARLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE
FORT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

1147 NW 64TH TER
GAINESVILLE FL
32605-4218
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-4400
  • Fax:
Mailing address:
  • Phone: 352-333-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME160698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: