Provider Demographics
NPI:1063598852
Name:LIPPMAN, IRA (OD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:LIPPMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MONTGOMERY MALL
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454
Mailing Address - Country:US
Mailing Address - Phone:215-362-2241
Mailing Address - Fax:215-362-8696
Practice Address - Street 1:205 MONTGOMERY MALL
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454
Practice Address - Country:US
Practice Address - Phone:215-362-2241
Practice Address - Fax:215-362-8696
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE5134T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1644263Medicaid
PA1644263Medicaid
PAT28738Medicare UPIN