Provider Demographics
NPI:1588992234
Name:WEBB, KIPP B (MD)
Entity type:Individual
Prefix:
First Name:KIPP
Middle Name:B
Last Name:WEBB
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 1:2001S WOODRUFF AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-523-3050
Mailing Address - Fax:208-523-4985
Practice Address - Street 1:2985 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-2985
Practice Address - Country:US
Practice Address - Phone:208-523-3373
Practice Address - Fax:208-523-8746
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6084207RC0000X
IDM-12781207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT63479Medicaid
MT63479Medicaid
MT9396Medicare PIN