Provider Demographics
NPI:1073564126
Name:IPSEN, JOHN DOUGLAS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAS
Last Name:IPSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53585 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-682-7133
Mailing Address - Fax:715-685-7857
Practice Address - Street 1:53585 NOKOMIS RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:715-685-7857
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37146207Q00000X
WI32307-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080005095OtherMEDICARE PIN
MN220313800Medicaid
MN220313800Medicaid