Provider Demographics
NPI:1174757140
Name:GIPSON, WILLIAM TERRY (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TERRY
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 JAY RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9775
Mailing Address - Country:US
Mailing Address - Phone:208-866-1634
Mailing Address - Fax:208-939-8277
Practice Address - Street 1:10455 JAY RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-9775
Practice Address - Country:US
Practice Address - Phone:208-866-1634
Practice Address - Fax:208-939-8277
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-57712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry