Healthcare Provider Details

I. General information

NPI: 1134305071
Provider Name (Legal Business Name): JONATHAN OREN LIPTON M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE DEPT OF FEGAN 11
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVENUE, DEPARTMENT OF NEUROLOGY FEGAN 11
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number224330
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number224330
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number235269
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: