Provider Demographics
NPI:1114956570
Name:KIPPER, STUART B (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:B
Last Name:KIPPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SYCAMORE AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7832
Mailing Address - Country:US
Mailing Address - Phone:760-598-1700
Mailing Address - Fax:760-598-1196
Practice Address - Street 1:910 SYCAMORE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7832
Practice Address - Country:US
Practice Address - Phone:760-598-1700
Practice Address - Fax:760-598-1196
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG61129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G611290Medicaid
CA2598333OtherGHI
CA110048716OtherRAILROAD MEDICARE
CA00G611290Medicaid
CAD88356Medicare UPIN
CAWG61129AMedicare PIN