Healthcare Provider Details

I. General information

NPI: 1558362319
Provider Name (Legal Business Name): DAVID S. LIPPIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD SUITE 112
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-7121
  • Fax: 260-436-4292
Mailing address:
  • Phone: 260-479-3514
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01041216A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: