Healthcare Provider Details

I. General information

NPI: 1376697094
Provider Name (Legal Business Name): EVAN JACOB LIPSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BROADWAY ST
BALTIMORE MD
21287-0031
US

IV. Provider business mailing address

PO BOX 64474
BALTIMORE MD
21264-4474
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-8893
  • Fax: 410-955-8587
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberD67921
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: