Provider Demographics
NPI:1124279831
Name:GIPSON, KEITH ERIC (MD, PHD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ERIC
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E RIVER DR
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3288
Mailing Address - Country:US
Mailing Address - Phone:860-282-4133
Mailing Address - Fax:860-289-0746
Practice Address - Street 1:99 E RIVER DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3288
Practice Address - Country:US
Practice Address - Phone:203-980-0368
Practice Address - Fax:860-289-0746
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT50552207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program