Healthcare Provider Details

I. General information

NPI: 1265497838
Provider Name (Legal Business Name): MARK J HIPPENSTIEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 CARATOKE HWY
MOYOCK NC
27958-8740
US

IV. Provider business mailing address

PO BOX 758963
BALTIMORE MD
21275-8963
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6621
  • Fax:
Mailing address:
  • Phone: 804-822-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101226438
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: