Provider Demographics
NPI:1073597258
Name:LIPPA, PEDRO C (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:C
Last Name:LIPPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:LIPPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1888 BROTHER GEENEN WAY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-7118
Mailing Address - Country:US
Mailing Address - Phone:941-566-3220
Mailing Address - Fax:
Practice Address - Street 1:1900 BROTHER GEENEN WAY
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-7102
Practice Address - Country:US
Practice Address - Phone:941-566-3220
Practice Address - Fax:941-955-8214
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74494208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263073700Medicaid
P00077861OtherRAILROAD MEDICARE
FLE66212TOtherMEDICARE
FL13485OtherBLUE CROSS/BLUE SHIELD
F81279Medicare UPIN
FL13485OtherBLUE CROSS/BLUE SHIELD