Healthcare Provider Details

I. General information

NPI: 1497928303
Provider Name (Legal Business Name): DEREK S. LIPMAN MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17704 JEAN WAY STE 105
LAKE OSWEGO OR
97035-5497
US

IV. Provider business mailing address

17704 JEAN WAY STE 105
LAKE OSWEGO OR
97035-5497
US

V. Phone/Fax

Practice location:
  • Phone: 503-675-6776
  • Fax: 503-675-2572
Mailing address:
  • Phone: 503-675-6776
  • Fax: 503-675-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD10662
License Number StateOR

VIII. Authorized Official

Name: DEREK S LIPMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 503-675-6776