Provider Demographics
NPI:1154371904
Name:LIPPER, GRAEME M (MD)
Entity type:Individual
Prefix:MR
First Name:GRAEME
Middle Name:M
Last Name:LIPPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TAMARACK AVE
Mailing Address - Street 2:ADVANCED DERM CARE PC
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811
Mailing Address - Country:US
Mailing Address - Phone:203-797-8990
Mailing Address - Fax:203-748-7861
Practice Address - Street 1:25 TAMARACK AVE
Practice Address - Street 2:ADVANCED DERM CARE PC
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-4829
Practice Address - Country:US
Practice Address - Phone:203-797-8990
Practice Address - Fax:203-748-7861
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040494207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001404946Medicaid
CT001404946Medicaid
CT070000448Medicare ID - Type Unspecified