Healthcare Provider Details

I. General information

NPI: 1083717862
Provider Name (Legal Business Name): JESSE TIPPETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 SHORT BRANCH DR SUITE 102
TRINITY FL
34655-4415
US

IV. Provider business mailing address

1807 SHORT BRANCH DR SUITE 102
TRINITY FL
34655-4415
US

V. Phone/Fax

Practice location:
  • Phone: 727-376-3547
  • Fax:
Mailing address:
  • Phone: 727-376-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME93868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: