Healthcare Provider Details

I. General information

NPI: 1366484990
Provider Name (Legal Business Name): VIKISHA TYESE FRIPP M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE
WASHINGTON DC
20017-2104
US

IV. Provider business mailing address

1150 VARNUM ST NE
WASHINGTON DC
20017-2104
US

V. Phone/Fax

Practice location:
  • Phone: 202-448-4080
  • Fax: 202-448-4082
Mailing address:
  • Phone: 202-448-4080
  • Fax: 202-448-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number057460
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number057460
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD039256
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: