Healthcare Provider Details

I. General information

NPI: 1497723886
Provider Name (Legal Business Name): DAVID GLEN TIPTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 602484
CHARLOTTE NC
28260-2484
US

V. Phone/Fax

Practice location:
  • Phone: 910-815-5830
  • Fax: 910-815-5698
Mailing address:
  • Phone: 910-815-5830
  • Fax: 910-815-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200401588
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: