Provider Demographics
NPI:1306919956
Name:LIPETZ, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:LIPETZ
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 1:535 KUPULAV DRIVE
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753
Mailing Address - Country:US
Mailing Address - Phone:808-874-1872
Mailing Address - Fax:808-874-5590
Practice Address - Street 1:41 E LIPOA STREET
Practice Address - Street 2:SUITE 22
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753
Practice Address - Country:US
Practice Address - Phone:808-891-1177
Practice Address - Fax:808-891-2255
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIB0222659OtherHMSA
HI08885703Medicaid
HIB0222659OtherHMSA
G77170Medicare UPIN