MEDICARE: SANDRA LIPOVACA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	13353	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13353	OTHER	NV	LICENSE

General Provider Information

NPI Number	:	1003144858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA LIPOVACA M.D.

Provider Business Mailing Address
First Line	:	5701 W CHARLESTON BLVD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1217
Country	:	US
Telephone Number	:	702-877-9514
Fax Number	:	702-312-3510

Provider Business Practice Location Address
First Line	:	1905 CIVIC CENTER DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7143
Country	:	US
Telephone Number	:	702-877-9514
Fax Number	:	702-312-3510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	10/29/2020

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