Healthcare Provider Details

I. General information

NPI: 1811972284
Provider Name (Legal Business Name): JOHN M LIPKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S VINE ST
BASTROP LA
71220-4513
US

IV. Provider business mailing address

425 S VINE ST
BASTROP LA
71220-4513
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-5422
  • Fax: 318-281-4416
Mailing address:
  • Phone: 318-281-5422
  • Fax: 318-281-4416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1021611
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1021611
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: