Provider Demographics
NPI: | 1265498836 |
---|---|
Name: | KIPPER, SAMUEL L (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | SAMUEL |
Middle Name: | L |
Last Name: | KIPPER |
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: | PO BOX 6279 |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46206-6279 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 866-727-1072 |
Mailing Address - Fax: | 800-508-4751 |
Practice Address - Street 1: | 1100 N TUSTIN AVE |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | SANTA ANA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92705-3509 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-835-6055 |
Practice Address - Fax: | 714-285-9084 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-24 |
Last Update Date: | 2014-05-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A34500 | 2085N0904X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085N0904X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00A345000 | Medicaid | |
360004475 | Other | RAILROAD MEDICARE | |
CA | 00A345000 | Medicaid | |
CA | EK898Y | Medicare PIN | |
360004475 | Other | RAILROAD MEDICARE | |
WA34500C | Medicare PIN | ||
WA34500B | Medicare PIN |