MEDICARE: GREGORY KIPP O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1387	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336411891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY KIPP O.D.

Provider Business Mailing Address
First Line	:	1206 OAK FOREST DR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-4022
Country	:	US
Telephone Number	:	386-673-4220
Fax Number	:

Provider Business Practice Location Address
First Line	:	3710 SAINT JOHNS AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-4026
Country	:	US
Telephone Number	:	386-328-1562
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GREGORY T. KIPP
Credential	:	O.D.
Telephone Number	:	386-673-4220

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	01/30/2012

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