Provider Demographics
NPI:1528068061
Name:GIPSON, VETRA ANETE (MD)
Entity type:Individual
Prefix:DR
First Name:VETRA
Middle Name:ANETE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4480 S COBB DR SE STE H
Mailing Address - Street 2:BOX 323
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6984
Mailing Address - Country:US
Mailing Address - Phone:404-805-5535
Mailing Address - Fax:866-935-5995
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:305-866-9951
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2024-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN47858207Q00000X, 208200000X
GA050518208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00963102AMedicaid
GA24BCBWKOtherMEDICARE ID
GA24BCBWKOtherMEDICARE ID