Healthcare Provider Details

I. General information

NPI: 1265498836
Provider Name (Legal Business Name): SAMUEL L KIPPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N TUSTIN AVE SUITE A
SANTA ANA CA
92705-3509
US

IV. Provider business mailing address

PO BOX 6279
INDIANAPOLIS IN
46206-6279
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-6055
  • Fax: 714-285-9084
Mailing address:
  • Phone: 866-727-1072
  • Fax: 800-508-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberA34500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: