=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528068061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VETRA ANETE GIPSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2005
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 SW 160TH AVE SUITE 250
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-866-9951
-----------------------------------------------------
Fax | 877-284-8933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4480 S COBB DR SE STE H BOX 323
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-6984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-805-5535
-----------------------------------------------------
Fax | 866-935-5995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 47858
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 050518
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 47858
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------