Healthcare Provider Details

I. General information

NPI: 1871094110
Provider Name (Legal Business Name): JOHN KENNETH LIPPINCOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 SEWALL ST
PORTLAND ME
04102-2625
US

IV. Provider business mailing address

53 SEWALL ST
PORTLAND ME
04102-2625
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2020
  • Fax: 207-773-7034
Mailing address:
  • Phone: 207-828-2020
  • Fax: 207-773-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number76892
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number76892
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD28019
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: